Purpose / Applicability:
To define standard cutoff times and fees for non-sterile and sterile compounding, including cleanroom use. This ensures safe and efficient workflow within the Medication Dispensary and appropriate staffing for after-hours requests.

Scope:
Applies to all non-sterile and sterile compounding activities and the use of the cleanroom within the Medication Dispensary.

General Policy

Due to staffing limitations outside standard compounding hours, requests made after the posted cutoff times won't be processed until the next business day unless the on-duty pharmacist approves. Using the cleanroom outside regular business hours or on an off-schedule basis will incur a $15 (non-hazardous) or $35 (hazardous) fee, and may include additional fees*, as detailed below.

*Fees are charged to the client but may also be billed to the service at their request. 

Non-Medication Dispensary staff are not allowed to perform any compounds during normal Medication Dispensary hours, unless the Reduced Staff protocol has been implemented for that day.

Standard Cutoff Times and Fees

Procedure:

 Non-Sterile Compounding

1. 1. Routine compounding ends at 5:00 pm.
   2. Requests appearing after 5:00 pm will be completed the next business morning, and the Medication Dispensary can ship the medications overnight at no cost to the client.
   3. Veterinarians may compound non-sterile medications after hours if needed.
2. Sterile Compounding / Cleanroom Use
   1. Routine sterile compounding ends at 4:00 pm.
   2. Requests after 4:00 pm require pharmacist approval and will incur applicable after-hours and cleanroom fees (see chart above).
   3. Cleanroom prep times are fixed at:
      1. Monday / Wednesday / Friday: 12:00 pm & 2:00 pm
      2. Tuesday / Thursday: 9:00 am, 12:00 pm & 2:00 pm
   4. Requests received after these times will be processed at the next available preparation window.
3. Weekend Compounding
   1. Compounding outside business hours (including weekends) incurs the standard after-hours and cleanroom fees.

 *Fees are charged to the client, but they may be charged to the service upon the service's request.

 Definitions:

 Non-Sterile Compounding: preparation, mixing, assembling, altering, packaging, or labeling of a drug or dosage form that does not require sterility.

Examples: Gabapentin oral suspension, Enrofloxacin/Dexamethasone otic solution, piroxicam capsules

2. Sterile Compounding (in Cleanroom): The preparation of medications intended for parenteral or other sterile routes of administration, where maintaining sterility throughout the process is critical. This includes repacking sterile medications, preparing injections, infusions, etc.

Examples: Cisapride 3mg/mL Injection, Butorphanol CRI syringe

3. Hazardous Sterile Compounding (in Cleanroom): The aseptic preparation of sterile medications that contain hazardous drugs (HDs) as defined by NIOSH (National Institute for Occupational Safety and Health), such as antineoplastics, hormones, or other agents with reproductive or carcinogenic risk.

Examples: Vincristine Injection, Cytarabine (Cytosar) solution, Doxorubicin Injection