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Chapter 11
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Identify the role and function of equipment used
in intravenous preparation and administration,
including syringes, needles, intravenous sets,
catheters, infusion pumps, and filters.
 Identify the components of an intravenous
administration set.
 Describe common characteristics of intravenous
solutions, including pH value, osmolarity and
osmolality, tonicity, compatibility, and stability.
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Created by Jennifer Majeske, Mineral Area College
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Summarize the steps necessary for aseptic
technique in a hospital pharmacy.
Describe the correct procedure used in
preparing compounded sterile preparations
from vials and ampules for hazardous and
nonhazardous agents.
Discuss the preparation of total parenteral
nutrition.
Differentiate between expiration dating and
beyond-use dating.
Created by Jennifer Majeske, Mineral Area College
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Understand the types of premade parenteral
products, including vial-and-bag systems and
frozen intravenous solutions, and their
handling requirements.
Calculate intravenous flow rate.
Discuss the importance of and techniques for
preparing, handling, and disposing of
hazardous agents.
Define the purpose and list examples of
quality assurance programs in the hospital.
Created by Jennifer Majeske, Mineral Area College
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Hospitals carry out unique activities, such as the
preparation, handling, and disposing of
hazardous drugs.
A major responsibility of the pharmacy tech
involves compounded sterile products (CSPs).
Aseptic technique – the processes and physical
preparation methods used by sterile
compounding personnel to avoid introducing
pathogens, into parenteral products.
Compliance with sterile compounding and
aseptic technique standards established by USP.
Reflected in Chapter <797> standards.
Created by Jennifer Majeske, Mineral Area College
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Syringes and Needles: used for withdrawing
or injecting solutions during the preparation
of CSPs.
IV push (IVP) – bolus administration; rapid
injection of a medication.
Syringes: made of glass or plastic; glass –
limited use, expensive; plastic – less
expensive, supplied in sterile packaging,
disposable.
Created by Jennifer Majeske, Mineral Area College
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Main components:
 Syringe tip
 Barrel – contains calibration marks
 Rubber-tipped piston plunger
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Technicians should choose the smallest
syringe that is able to hold the desired
volume; at least ¾ full.
Technicians should count the number of
marks between labeled measurement units,
to get the most accurate dose.
The volume of solution is measured at the
point of contact between the rubber-tipped
piston plunger and the inside of the barrel.
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Needles are made of stainless steel or
aluminum.
Needle size is determined by length and
gauge.
Lengths range from 3/8 inch to 6 inches.
Gauge refers to the diameter of the opening;
the larger the gauge number the smaller the
opening (or size of the lumen).
 31-gauge (smallest bore)
 13-gauge (largest bore)
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Parts of a Needle:
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Needle tip
Bevel
Heel
Needle shaft
Needle lumen
Needle hub
Handling of the Needle-and-Syringe Unit:
 A syringe comes from the manufacturer in sterile
packaging.
 Sterile compounding personnel must not touch the
sterile parts or critical sites of the syringe or needle.
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Critical site – the part of
the supply item that
includes any fluidpathway surface or
opening that is at risk
for contamination
by touch or
airflow interruption.
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Created by Jennifer Majeske, Mineral Area College
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IV administration set – a sterile, disposable
device used to deliver IV fluids and injectable
medications directly into a patient’s vein.
IV sets do not have expiration dates, but do
contain “Federal law restricts this device to
sale by or on the order of a physician.”
An IV infusion pump is nondisposable,
reusable equipment often referred to as
durable equipment.
Created by Jennifer Majeske, Mineral Area College
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Universal spike adaptor (tubing spike or spike)
 Pierces the rubber stopper or port of the IV
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Drip chamber
 Allows healthcare personnel to view and count drops
of IV fluid
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Roll clamp
 Adjust flow rate
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Flexible tubing
 Delivers the fluid
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Needle adaptor
 Attaches a needle or catheter to the patient
Created by Jennifer Majeske, Mineral Area College
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Universal Spike Adaptor: spike – used to
pierce the IV’s tubing port; some IV sets have
an air vent.
Drip chamber – hollow drip chamber; allows
any air bubbles to rise to the top of the IV
fluid.
Drop set – number of drops it takes to make 1
mL; also know as the tubing’s drop factor.
Macrodrip set: 10, 15, 20 gtts/mL
Microdrip or minidrip set: 60 gtts/mL
Created by Jennifer Majeske, Mineral Area College
Roll Clamp – a hard, plastic clip that contains a
smaller roller allowing control of the flow of
fluid.
 Flexible tubing – IV tubing, molded from pliable
PVC and other plasticizers.
 Needle adaptor – usually located at the distal
end of the IV set, close to the patient.
 Additional Components of an IV set:
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 Y-site injection port – allows medication to be added
to the IV solution
 In-line filter – provides protection against particulates
Created by Jennifer Majeske, Mineral Area College
Length of IV sets vary, ranging from 6 to 120
inches.
 What determines length of IV tubing?
 Priming – the action of flushing out the small
particles in the tubing’s interior lumen before
medication administration.
 The amount of fluid needed to prime the tubing
depends on the length of the set – 3 to 15 mL.
 In-line filters has reduced the need for flushing
the line with IV fluid before administration.
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Created by Jennifer Majeske, Mineral Area College
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Nurses typically administer IV solutions to
patients by attaching the IV tubing to the
fluid container, establishing flow rate, and
managing overall regulation.
Catheter – tube, implanted in the patient and
affixed to the patient’s skin.
IV sets are changed every 24 – 96 hours to
minimize the risk of infection.
Created by Jennifer Majeske, Mineral Area College
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Changes in the scope of pharmacy practice
make it necessary for pharmacy personnel to
have a complete understanding of IV sets and
their operations.
Pharmacist may:
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Select IV sets
Serve on CPR or code teams
Provide in-service training
Use IV sets when transferring fluids
Prime IV sets
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Filter – a device used to remove contaminants
such as glass, fibers, and tiny bits of rubber that
may have inadvertently entered the CSP during
sterile compounding.
 Depending on size, filtration should protect the
patient.
 Filters do not remove virus particles or toxins.
 Common filter sizes:
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 0.5 micron: random path membrane
 0.45 micron: in-line filter
 0.22 micron: removes bacteria to produce a sterile
solution
Created by Jennifer Majeske, Mineral Area College
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Most IV preparations are comprised of
ingredients added to a sterile water medium
or base solution.
Certain chemical properties or characteristics
are needed of these preparations so damage
does not occur to the patients blood cells or
vessels or alters the chemical properties of
blood.
CSPs must possess chemical characteristics
similar to blood serum.
Created by Jennifer Majeske, Mineral Area College
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Beyond-use date – the date and time after
which a CSP is no longer sterile, stable, or
effective.
pH Value – the degree of acidity or alkalinity of a
solution.
 Less than 7.0 = acidic
 Greater than 7.0 = basic (alkaline)
 Blood plasma pH 7.4
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IV solutions should have a pH that is neutral
(near 7.0) so they don’t adversely affect the pH
of the blood.
Created by Jennifer Majeske, Mineral Area College
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Osmolarity – a measure of the number of
milliosmoles of solute per liter of solution (mOsm/L).
 Blood plasma = 285 mOsm/L
Osmotic pressure – the pressure required to maintain
equilibrium, with no net movement of solution across
body membranes.
 Osmolality – a measure of the number of
milliosmoles of solute per kilogram of solvent.
 An IV preparation must be isoosmotic, meaning the
solution should have the same number of particles in
solution per unit volume and the same osmotic
pressure as blood.
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Created by Jennifer Majeske, Mineral Area College
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Hypotonic solution – hypoosmolar solution;
fewer number of dissolved particles than blood
cells; water is drawn into cells, causing cells to
swell.
 0.45% normal saline (NS)
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Hypertonic solution – hyperosmolar solution;
greater number of dissolved particles than blood
cells; water is drawn out of cells, causing cells to
shrivel.
 50% dextrose or 3% sodium chloride
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Isotonic solution – similar number of dissolve
particles as blood.
 0.9% NS
Created by Jennifer Majeske, Mineral Area College
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Compatibility – the ability to combine two or
more base components or additives within a
solution, without resulting in changes to the
physical or chemical properties of the
additives.
Stability: is affected by storage conditions;
some IV medications need to be refrigerated
or frozen after compounding; amber-colored
bags protect the drug from exposure to light.
Created by Jennifer Majeske, Mineral Area College
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Multiple IV solutions are available.
Most common used IV infusions are dextrose
in water, normal saline, or dextrose in saline.
Table 11.1 pg. 444 Commonly Used IV
Products and Abbreviations
Technicians typically compound two types of
CSPs:
 Large-volume parenterals
▪ Primary source of hydration
 Small-volume parenterals
▪ “piggybacked”
Created by Jennifer Majeske, Mineral Area College
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Large-volume parenteral (LVP) – is used to
replenish fluids and to provide drugs,
electrolytes, and nutrients such as vitamins,
minerals, and glucose.
LVPs commonly available:
 250 mL, 500 mL, and 1000 mL
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Potassium chloride is the most common
additive.
Lactated Ringer’s Solution – IV solution that
contains a specific mixture of electrolytes.
Created by Jennifer Majeske, Mineral Area College
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Small-volume parenteral (SVP) – a CSP that is
dispensed in a minibag; over a short time period
10 minutes to an hour.
SVPs commonly available:
 25 mL, 50 mL, 100 mL, 150 mL, or 250 mL
IV piggybacks (IVPBs) – majority of SVPs
prepared; small volume (50 to 100 mL) of a base
solution (D5W) and a medication.
 Special SVP solutions include frozen IV
solutions, premade IVPBs, and vial-and-bag
systems.
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Created by Jennifer Majeske, Mineral Area College
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A CSP label should contain the following:
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Patient’s name and id #
Room number
Medication name and dose
Base solution and amount
Infusion period
Flow rate
Beyond-use date
Signature or initials
Additional information
Created by Jennifer Majeske, Mineral Area College
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Sterile preparations of IV medications by
pharmacy personnel include single- and
multi-dose vials, ampules, and other
containers that must be transferred to an LVP
or SVP.
CSPs must be prepared in an ISO Class 5
laminar airflow hood.
Table 11.2 pg. 447 Summary of Procedures to
Maintain Aseptic Technique During Sterile
Compounding
Created by Jennifer Majeske, Mineral Area College
Vials – a sealed, sterile, plastic or glass container
that has a hard plastic cap; sizes range from 1
mL to 250 mL.
 Types of vials:
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 Single-dose vials (SDV)
▪ do not contain a preservative
▪ one-time use
▪ used within 1 hour or discarded
 Multi-dose vials (MDV)
▪ do contain a preservative
▪ stable for 28 days
Created by Jennifer Majeske, Mineral Area College
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First disinfect the rubber stopper with 70%
isopropyl alcohol.
Pierce the rubber top with a needle-andsyringe unit.
Bevel up; penetrate at an angle; straightened
to 90 degrees.
Coring – the inadvertent introduction of a
small piece of rubber top into the solution.
A milking technique must be used to release
negative pressure within the vial.
Created by Jennifer Majeske, Mineral Area College
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Some medications come freeze-dried
(lyophilized), and need to be reconstituted
with a diluent such as sterile water or NS
before being injected into the IV.
Vented needle – allows the diluent to be
injected into the vial while simultaneously
venting the positive pressure that has built up
within the vial.
Created by Jennifer Majeske, Mineral Area College
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The technician should arrange the vial, filled
syringe, and the IV or IVPB base for a
pharmacists final check.
The pharmacist then verifies the technicians
work.
After verification the technician can proceed
with preparing the CSP; checking for leaks
and signs of incompatibility and labels the
CSP for delivery.
Created by Jennifer Majeske, Mineral Area College
Ampule – a small,
hermetically sealed
container that has a distinct,
elongated neck.
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 Contains no preservative
 Some drugs are only available in an
ampule because of incompatibility with rubber
or PVC components of vials
Parts of an Ampule:
head, neck, shoulder,
and body.
 Break ring – a scored area on the neck that
marks the site where a technician will break the
glass to access the ampule’s contents.
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Created by Jennifer Majeske, Mineral Area College
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Opening an Ampule: safe opening of an ampule
can be done with a piece of gauze, sterile 70%
IPA swab or a ampule breaker a small plastic cap,
placed over the head of an ampule.
 Hold the ampule upright, clear the medication from
the head and neck.
 Clean the neck of the ampule.
 Hold the ampule in the non-dominant hand, grasping
the head of the ampule with the dominant hand.
 Exert firm but gentle pressure on the break ring to
snap the ampule’s neck.
Created by Jennifer Majeske, Mineral Area College
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Withdrawing Medication from an Ampule:
hold the ampule upright; bevel down in the
corner near the opening.
When the ampule is nearly empty, tilt the
ampule slightly to allow easier access to the
remainder of the medication.
A filter needle should be used when drawing
medication out of an ampule to avoid glass
fragments.
Created by Jennifer Majeske, Mineral Area College
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Preparing a CSP with an Ampule’s Contents:
similar to the process of preparation for a vial
so that it can be checked by the pharmacist.
The pharmacist verifies the technicians work.
After verification the technician may proceed
with the making of the CSP.
Lastly, the technician will need to check for
leaks and signs of incompatibility and label
the CSP for delivery.
Created by Jennifer Majeske, Mineral Area College
Total parenteral nutrition (TPN) – IV solutions
that provide long-term nutritional support for a
specific patient population.
 Why might a patient need a TPN?
 TPN Components: approximately 15
components including:
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Sterile water for hydration
Dextrose for calories and energy
Amino acids for protein synthesis
Fatty acids for chemical processes and energy
Additives: electrolytes, vitamins, and minerals
Medication for treatment of a disease or disorder
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Preparing a TPN: 1,000 to 2,000 mL to
provide nutritional support for 12 – 24 hours.
Automated compounding device (ACD) –
for the preparation of large volumes of TPN
solutions.
IV fat emulsion is known as a 3-in-1 TPN
solution.
Administering TPN: central venous catheter
(CVC) – central line, into the subclavian vein –
is required form the administration of a TPN.
Created by Jennifer Majeske, Mineral Area College
Created by Jennifer Majeske, Mineral Area College
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Premade parenteral products benefits the
hospital pharmacy, the nursing staff and the
patients.
These commercially available products come as:
 Vial-and-bag systems
 Frozen sterile IV solutions
The expiration date varies compared with
standard beyond-use dating.
 The expiration date is based on scientific studies
and can be found on the product, and can be
found on the vial or in the product package
insert.
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Vial-and-bag system – provides both a single
vial of powdered medication with an adaptor
and a specified IV solution that acts as the
diluent.
Types of Vial-and-Bag Systems: ADDVantage (Hospira), MINI-BAG Plus (Baxter
Healthcare); not considered CSPs.
Stability and expiration date varies with the
type and concentration of the drug, diluent,
storage conditions, and activation.
Created by Jennifer Majeske, Mineral Area College
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Some of the benefits of vial-and-bag systems
include less wastage, improved safety,
efficiency, and cost-effectiveness.
Safety: admixing errors are minimized; risk of
contamination is also minimized.
Efficiency: doses are premeasured for rapid
reconstitution and easy assembly.
Cost-effectiveness: no admixing is necessary
and no additional supply costs.
Created by Jennifer Majeske, Mineral Area College
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Each vial-and-bag system differs somewhat,
but the concept is similar.
The vial of drug – that is not reconstituted – is
coupled (with or without an adaptor) with an
appropriate volume of IV solution.
Assembly: the technician is responsible for
assembly; performed in the hood to maintain
sterility.
Activation: nursing staff is responsible for
activation.
Created by Jennifer Majeske, Mineral Area College
Commercially available products and are not
considered CSPs.
 Most are antibiotics and are manufactured as SVPs in
a premixed frozen state.
 Handling of Frozen IV Solutions: kept in the freezer
until an order is received; the product is then thawed
at room temp. or in the refrigerator.
 Expiration date varies with the drug and storage
conditions.
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 Ancef – expiration date of 48 hours at room temp., 30 days
in the refrigerator
 Zosyn – expiration date of 24 hours at room temp., 14
days in the refrigerator
Created by Jennifer Majeske, Mineral Area College
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Certain calculation skills are necessary by a
pharmacy technician who prepares CSPs.
Most dosage calculations are done by the
pharmacy technician.
IV flow rate is used to calculate days supply
for IVs and IVPBs.
Calculation and verification differs for
chemotherapy agents, neonatal IV
medications and certain TPN preparations.
Created by Jennifer Majeske, Mineral Area College
Daily IV run or batch – preparation of all CSPs needed
for all patients during a specific period.
 Calculations address the following questions:
 What is the infusion rate in mL/hour?
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 Divide total volume by the number of hours: TV/H = x
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How long will this bag last?
 Divide the total volume by the infusion rate: TV/IR = x
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What time will the next bag be needed?
 Add the number of hours calculated, (x) calculated in the
previous step to the current standard time
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How many bags will be needed for the patient in a 24hour period?
 Divide 24 by the number of hours calculated in the
previous step (x).
 Examples 1-4
Created by Jennifer Majeske, Mineral Area College
Electrolyte solution – IV fluid containing
dissolved mineral salts.
 What is the most common electrolyte additive?
 Electrolyte solutions are measure in
milliequivalents (mEq).
 Pharmacy technicians must use pharmacy math
formulas to determine the amount of additive
that must be drawn up to provide a prescribed
dosage.
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 Example 5
Created by Jennifer Majeske, Mineral Area College
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Hazardous agents require special handling
and preparation by pharmacy personnel.
Cytotoxic drug – any drug that destroys
cancer cells.
Antineoplastic drug – reduces or prevents
the growth of cancer cells.
Before 1980, there were few safety standards
for handling of hazardous drugs.
There exists persistent contamination in both
preparation and patient care areas.
Created by Jennifer Majeske, Mineral Area College
Trauma or injury: accidentally prick oneself with a
needle or cut from a broken container
2. Inhalation of the hazardous substance: releasing a
fine mist of medication and inadvertently inhaling
the substance
3. Ingestion: ingest minute powder when crushing an
oral tablet or cleaning a tray
4. Direct skin contact: accidental spill
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Asparaginase can cause skin irritation
Doxorubicin can cause tissue death and sloughing
Nitrogen mustards can cause irritation of the eyes, mucous
membranes, and skin
Steptozocin is a potential carcinogen if it comes into
contact with skin
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Healthcare workers with exposure to hazardous
agents can suffer acute, chronic and long-term
health consequences.
 Risks should be understood by a woman of
reproductive age who routinely works with
hazardous agents.
 Incorrect aseptic technique may result in
contamination and potential infection.
 Closed-system transfer devices (CSTDs) are
increasingly being used to prepare and
administer hazardous drugs.
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Created by Jennifer Majeske, Mineral Area College
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USP Chapter <797> indicates the donning of
protective clothing when working with
hazardous agents.
The gown should be a disposable, lint-free,
impervious, and closed-front.
Hair cover and shoe covers; eye protection,
face mask, chemotherapy gloves worn over
sterile disposable gloves (double gloving).
Created by Jennifer Majeske, Mineral Area College
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Gloves need to be worn when preparing
hazardous agents, as well as when receiving,
stocking, inventorying, and disposing.
Storage areas should be labeled: “Caution:
Hazardous Agents.”
Refrigerated hazardous agents should be
stored separately from other drugs.
Access to hazardous materials should be
limited to trained personnel.
Created by Jennifer Majeske, Mineral Area College
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Strict aseptic techniques should be used in
the preparation of CSPs that contain
hazardous agents.
Biological Safety Cabinet (BSC) – a
specialized hood that is used to prepare
chemotherapy drugs and other hazardous
compounds.
Compounding Aseptic Containment
Isolator – a vertical airflow hood that is used
in the preparation of hazardous drugs.
Created by Jennifer Majeske, Mineral Area College
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Specialized Supplies:
Closed-System Transfer Devices – a double
internal needle transfer with duel membranes to
provide a tight seal connection.
Chemotherapy Compounding Mat – a thin mat
whose side is made of absorbent material to
soak up potential fluid spills within the BSC.
Chemotherapy Dispensing Pin – chemo pin –
small plastic device that has a spike at one end
and an adaptor at the other end.
Created by Jennifer Majeske, Mineral Area College
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Hazardous CSPs may need to be prepared from
a vial.
If a CSTD is not available, a vented
chemotherapy dispensing pin may be used to
safely withdraw fluid from a hazardous drug vial.
Negative pressure techniques: no introduction
of air into the vial or by introducing a volume of
air that is less than the solution volume to be
withdrawn.
Never inject into a hazardous drug vial more
than 75% of the volume that you plan to
withdraw.
Created by Jennifer Majeske, Mineral Area College
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The process of withdrawing a hazardous drug
from an ampule is the same as with a non
hazardous drug.
A 5 micron filter needle should be place on
the syringe to withdraw the solution from the
ampule.
A standard needle is then used to inject the
fluid into an IV or IVPB.
Created by Jennifer Majeske, Mineral Area College
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Hazardous oral drugs can be handled in
community, home healthcare, long-term care
and hospital pharmacies.
Counting and pouring of these medications
should be done carefully, and counting trays
should be immediately cleaned after use.
Crushing of hazardous drugs should be done
by placing the medication in a small, sealable
plastic bag and crushing with a spoon or
pestle.
Created by Jennifer Majeske, Mineral Area College
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Occasionally prepared in a nuclear pharmacy
by a specially trained and certified nuclear
technician.
Handling, preparation, and disposal of
radioactive agents are beyond the scope of
this class and text.
http://www.ehow.com/facts_6822371_nuclea
r-pharmacy-technician-certification.html
Created by Jennifer Majeske, Mineral Area College
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Priming and IV Administration Set:
 Wipe with sterile 70% IPA
 Transported in a sealed plastic bag
 Priming should be done in the BSC or CACI
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Labeling Hazardous Agents:
 Patient’s name and room number, solution name and
volume, drug name(s) and dosage, CSP
administration information and storage requirements
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Administering Hazardous Agents:
 A nurse must wear a mask, gloves and a special gown
Created by Jennifer Majeske, Mineral Area College
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Pharmacy personnel, in the event of a
hazardous agent spill, must be aware of
proper cleanup procedures and disposal.
Spill kits
Why when cleaning up a spill should you work
from the outside in?
Spill, cleanup and personnel exposure must
be documented.
Created by Jennifer Majeske, Mineral Area College
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Material Safety Data Sheet (MSDS) or Safety
Data Sheet (SDS) outlines specific
recommendations on how to handle exposure to
a hazardous substance.
Skin exposure – flush affected area immediately;
cleanse area with soap and water.
Eye contact – flush the eyes with large amounts
of water.
Remove contaminated garments; wash hands;
go to the emergency room.
Created by Jennifer Majeske, Mineral Area College
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Inspection of CSP: accuracy; technique;
packaging; labeling; physical appearance.
When combining one than more drug there is
the likelihood of physical incompatibility.
Combining an acidic and alkaline salt may
result in a solid precipitate.
Reference for physical drug incompatibility is
Trissel’s Stability of Compounding
Formulations.
Created by Jennifer Majeske, Mineral Area College
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Delivery of a CSP must be done without
damage to the package.
Proper storage conditions must be met.
IV administration times must be documented
by the nurse in the medication administration
record (MAR).
Proper labeling and storage of CSPs is
necessary if to be administered at a later
time.
Created by Jennifer Majeske, Mineral Area College
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What if a CSP is returned? When can a CSP be
re-dispensed?
CSP storage conditions must be met by the
nursing unit, what happens if they are not?
What about the return of vial-and-bag
systems?
Created by Jennifer Majeske, Mineral Area College
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Quality assurance (QA) program – detect
and correct errors; identify problems and try
to correct them so they do not recur.
What can occur if there is a breakdown in
accuracy?
The QA program is to be outline in the
hospital pharmacies P&P manual.
Following appropriate aseptic technique
minimizes microbial contamination.
Created by Jennifer Majeske, Mineral Area College
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Personal training and proper handling of
CSPs and hazardous agents documentation is
required by USP Chapter <797> and Joint
Commission standards.
What areas of training must be covered for
hazardous agents?
Training must be documented and repeated
each year.
Created by Jennifer Majeske, Mineral Area College
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Created by Jennifer Majeske, Mineral Area College
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Slide 43
 Subclavian vein by Anatomist90 licensed under CC
BY
Created by Jennifer Majeske, Mineral Area College