Personnel Training and Evaluation
Sterile Hazardous Compounding <800>

Purpose/ Applicability:  To provide guidelines for training and evaluating personnel to show competency in safely and properly handling sterile hazardous compounds.

Scope: Applies to all personnel who handle sterile compounded hazardous preparations.

Definition(s):

          HD: Hazardous Drugs

PPE: Personal Protective Equipment

SOP: Standard Operating Procedure

Equipment: N/A

Procedure:

Background

• Personnel who are compounding sterile hazardous preparations must be trained in properly donning PPE and in aseptic and negative pressure techniques that are necessary for working with sterile HDs
• Additional training is required when new equipment, new HD, or new procedures are put in place
• Personnel competency must be reassessed every 12 months and documented appropriately (in the form below)

Training Categories

Personnel must be trained and show competency in:

• Spill management and the necessary documentation
• Receipt, transport, and storage of HDs
• Dispensing and administering HDs
• Proper use of equipment and devices (i.e. engineering controls)
• Response to known or suspected HD exposure
• Overview of formulary and risks of HDs carried
• Aseptic techniques
• Proper labeling
• Cleaning, sanitizing, deactivation, and decontamination of HDs
• Proper disposal of HDs and trace contaminated materials
• Proper donning and doffing of PPE
• Daily cleaning and disinfection of cleanroom

 Training for Handling of Hazardous Drugs:

• Personnel should review all appropriate SOPs, complete cleanroom certification (donning/doffing of PPE), and review cleanroom cleaning and disinfection procedures
• Following reviews, personnel should be able to communicate procedures effectively and appropriately