D.4 Appendix C Competency Assessment Hazardous Drug Manipulation Technique

?.## APPENDIX C_COMPETENCY ASSESSMENT_HAZARDOUS DRUG MANIPULATION

TECHNIQUE

Appendix C
Competency Assessment: HD manipulation technique and conduct in the hazardous buffer room/C-SCA
Type: ___ Initial Competency ___ Ongoing Competency
Observations and subsequent evaluation must be made by qualified pharmacy staff. Using the space designated next to each criterion, the evaluator will initial to signify that the criterion has been satisfied.
Skill
Demonstrates understanding that hazardous
medications should be prepared in a Biological Safety
Cabinet (BSC).
Demonstrates understanding that if the exhaust fan on
a BSC is turned off, the cabinet must be
decontaminated before reuse.
Cleans/decontaminates the BSC with Peridox followed
by sterile 70% IPA appropriately during the following
times:
- When there are spills
- Before and after certification
- Any time voluntary interruption occurs
- If the ventilation tool is moved
- At the end of the work shift
Once weekly, decontaminates the area underneath the
work surface of the BSC
Collects correct medications, solutions, and supplies.
Inspects vials, ampules, IV bags for
damage/contamination and expiration date before
compounding.
Wipes appropriate medications and supplies with
sterile 70% IPA before placing them in the BSC.
Demonstrates proper placement of items in the BSC to
prevent blocking air flow. Keeps nonessential items
outside BSC.
Checks labels both prior to and after compounding to
ensure medications and solutions being used agree.
Lowers glass safety shield to no more than an 8-inch
opening during admixture operations.
Demonstrates understanding of air flow in BSC,
maintains flow of clean air over objects in BSC, does

Initials

Comments

not interrupt air flow. Places only hands and arms in
BSC.
Does not utilize outer 6 inches of BSC opening, work
too close to the sides of BSC, or block air intake grills during admixture preparation.
Does not take hands out of BSC or leave the BSC
during admixture preparation.
Does not touch or contaminate any component that
must remain sterile during admixture preparation.
Performs all work on plastic-backed paper mat placed
on the work surface.
Demonstrates proper swabbing and entering of vials,
ampules, and bags.
Correctly uses appropriate transfer devices (closedsystem transfer devices, Luer-Lok syringes, filter needles, vented needles, dispensing pins, etc.).