Department of Pharmacy Policies & Procedures

Number: 1:08

Effective Date: October, 1990

Revisions: 10/96; 5/09

Approval: 11/96

Subject: PHARMACY SAFETY

I. POLICY

Pharmacy employees shall be encouraged to exercise good safety practices while at work. Employees shall observe the general safety rules which are part of the hospital safety policy with special emphasis on those of specific interest in the pharmacy department.

II. GENERAL PROCEDURES

1. Each employee will be acquainted with the safety policy during hospital orientation. Each person will be given a thorough orientation that covers any hazardous operation specific to their work area.

2. Each employee will be oriented to the Material Safety Data Sheets maintained in the pharmacy and instructed in what they mean and how to use them.

3. Employees involved in handling and mixing cytotoxic drugs will be oriented to the cytotoxic drug handling policy and expected to follow it.

4. There will be no unauthorized electrical extension cords used in the pharmacy.

5. Emergency equipment such as fire extinguishers or chemical spill kits must be kept free from obstruction and easily accessible.

6. Each employee will be educated in Fire Safety and Disaster Preparedness and receive training annually.

7. Responsible behavior is expected by each employee. There will be no horseplay, pushing, shoving, throwing objects or other such acts in the area.

III. FIRE SAFETY

1. The hospital fire plan is referred to as CODE RED. This plan is implemented when fire and/or smoke are reported within UAMS Medical Center.

2. The procedure for pharmacy in the event of fire is:

• Activate the nearest Fire Alarm Pull Station.
• Dial 686-5333 and tell the operator that there is a CODE RED situation and identify the area and if possible the extent of the fire.
• Use the Fire Extinguisher on the fire if this is practical.
• Evacuate the area if the fire or the smoke is in the pharmacy.

3. When evacuation of personnel or patients is necessary.

• Do not use the elevators. Always use a stairway.
• Pharmacy personnel who are staffing the satellites should be available to help move patients if necessary.
• If the fire occurs in the satellite itself, evacuate the area, close the door to the room, and remain in the immediate hallway until the fire department comes or the floor must be evacuated.

IV. CHEMICAL SAFETY

1. All chemicals stored in the pharmacy or the flammables storage building must be properly labeled with a manufacturer’s label or a pharmacy label which follows the labeling format.

2. Any area in which chemicals are handled must have a water supply available for emergency washes.

3. Clean-up supplies or spill kits must be available in all areas where chemicals are handled.

4. All personnel who handle chemicals as part of their usual job must be educated in proper emergency techniques.

5. Laboratory safety glasses or protective eye goggles will be worn when there is a splash danger from use of caustic chemicals.

6. All flammables stored in the pharmacy shall be in approved flammable storage cabinets.

7. All pipetting will be accomplished using safety pipetting bulbs.

8. The chemical hood(s) will be used for all procedures which may produce noxious fumes including all evaporations.

V. FLAMMABLE STORAGE SAFETY

1. All explosive solvents will be stored in the walk-in cooler which is part of the storage building.

2. Non-sparking tubing shall be used on the air compressors which are used to pump flammables from 55 gallon drugs.

3. Air compressors will be kept outside the doors of the building when in use.

4. All containers will be stored closed.

5. All flammable products stored in the pharmacy will be stored in a flammables storage cabinet with the exception of partial bottles being used as working stock and commercial packages of ethyl “rubbing” alcohol 70% USP and isopropyl alcohol 70% which used in the pharmacy department for disinfecting.