Implementation of USP Chapter Standards and a Risk Assessment Tool for a Community Hospital S.Allen, R.Lucas, J.Ezell, A.Porter, E.Duncan, S.Grimes, F.Pruss Blount Memorial Hospital - Maryville, TN
Background/Purpose: USP Chapter establishes standards that must be followed by healthcare entities when handling hazardous drugs. The primary objective is to identify and develop policies, procedures and a risk assessment tool to ensure Blount Memorial Hospital (BMH) meets full compliance with USP Chapter standards.
Methodology: A pre-implementation gap analysis was performed to identify practices not meeting full USP Chapter compliance. A hospital departmental review was initiated, determining those involved with hazardous drugs. A pre and post implementation questionnaire with education assessed pharmacy staff comprehension of USP Chapter requirements; their knowledge level will determine future education techniques. A risk assessment tool was created to determine drug specific handling precautions. A second gap analysis will be performed to narrow deficiencies.
Results: (Preliminary) The pre-implementation gap analysis identified 59 out of 194 areas not fully meeting USP Chapter requirements. Administration of a pre-implementation USP Chapter comprehension questionnaire to pharmacy staff assessed education deficiencies and resulted in an average score of 77 percent; post-education assessment resulted in an average score of 96 percent. Identified hazardous medications on formulary are being evaluated with the created risk assessment tool. A second gap analysis is currently in process.
Presentation Objective: Describe steps taken to become USP Chapter compliant and to develop a continued compliance risk assessment tool.
Self-Assessment: Which of the following are effective steps to assess USP Chapter compliance and to determine specific drug handling precautions:_x000D_ _x000D_ A.Review existing hazardous drug handling policies_x000D_ B.Perform a gap analysis_x000D_ C.Educate staff on USP Chapter _x000D_ D.Create a risk assessment tool_x000D_ E.All of the above_x000D_ _x000D_
