It is the responsibility of the pharmacy department to insure that drug products prepared and dispensed in the hospital are free from infectious agents by strict adherence to aseptic technique and routine infection control procedures.

A. Health:

1. Pharmacy personnel must fulfill all pre-employment and annual health requirements as outlined in the Infection Control Manual. This includes required testing and/or immunizations.

2. Pharmacy personnel must have annual TB screening.

3. Personnel will be free of transmissible infection.

4. No one with a febrile respiratory, skin, or mucocutaneous (including herpes), hepatic, gastrointestinal or other communicable infection should have extended patient contact or prepare any drug products for patients. Personnel should report such infections to their immediate supervisor for evaluation.

B. Orientation and Instruction:

New employee orientation will include an overview of Infection Control with emphasis on the importance of hand hygiene. Specific infection control policies will be included in the department orientation and other inservices will be scheduled as necessary. All employees will be encouraged to attend the annual Infection Control update and review the Infection Control Manual at least annually for updates and/or changes.

C. Attire:

All personnel will wear clean, neat clothing in compliance with departmental regulations.

D. Eating and Smoking.

No smoking is allowed in patient care areas or in the pharmacy. No eating or drinking will be allowed except in designated break areas.

III. General Infection Control Measures:

A. Hand Hygiene - Refer to Comprehensive Infection Control Manual Addendum D.

B. Universal Precautions- Refer to Comprehensive Infection Control Manual Addendum B.

C. Blood and Body Fluids - Refer to Comprehensive Infection Control Manual 6.03 Blood and Body Fluids.

D. Isolation Precaution - Refer to Comprehensive Infection Control Plan Addendum B.

IV. Pharmacy Specific Infection Control Policies

A. Personnel

1. Hand Hygiene -

• Routine handwashing - vigorous washing with soap under a stream of water for at least 15 seconds for all staff is indicated when coming on duty , before and after eating, after any personal hygiene activity and before going off duty as well as after any overt contamination.

• Antiseptic handwashing - vigorous washing with an antiseptic handwashing product (iodophor or chlorhexidine) under a stream of water for at least 15 seconds. Waterless handwashing agents (>/= 60% alcohol as a foam, gel, or liquid) may be used if hands are not visibly soiled. Follow manufacturer's directions.

2. Aseptic technique - Only pharmacists thoroughly trained in aseptic technique and certified as competent by Quality Assurance will prepare IV fluids without supervision. Technicians who have been certified in the IV training program may prepare IV fluids under the supervision of the pharmacist.
3. Gloves - Gloves shall be used if the employee has cuts or other open wounds on the hands and is working in the laminar flow hood. Gloves shall be used when handling medication during prepackaging into unit dose packages.
4. Illness - Any pharmacist found to have a respiratory infection or any condition which would prohibit exercising good aseptic technique will be assigned to an area other than IV preparation for the duration of the illness. In the event a replacement cannot be found for a pharmacist with a mild cold, he/she may proceed with IV compounding providing a particulate respirator mask is worn at all times.

B. Environmental

• Hood Maintenance - Laminar Flow hoods will be operated and maintained in accordance with established pharmacy procedures. This will include inspection certification every six (6) months, and routine cleaning and filter changes.

2. Housekeeping -

• Pharmacy personnel will prevent the accumulation of cardboard containers or any bulk containers that would impede proper cleaning of the area.
• Food and drink will not be permitted on counters or kept in storage in the area.
• All refrigerators will be thoroughly cleaned as indicated.

D. Procedural/Manufacturing

• The pharmacy production area will adhere to Good Manufacturing Practices, a complete control program, and utilize a strict quarantine system for manufactured products.
• Refer to Section 7:00 for specific control functions for the various areas found in the manufacturing department.
• All batches of sterile manufactured products will be assayed to assure sterility and the Quality Assurance pharmacist will have the authority to reject any batch that does not meet control standards.

E. Miscellaneous

• Disposal of Live Vaccines - Live attenuated vaccines will be returned to the pharmacy for autoclaving prior to disposal.
• Multi dose vials - Refer to Section 8:03.5 for procedures in handling vials.