Pharmacy Technician Sterile Products Compounding

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A Brief Overview
Assist in various pharmacy activities, under the supervision of a licensed pharmacist, and other duties not requiring the review of a pharmacist. The majority of tasks and responsibilities are related to preparing, dispensing, and distributing compounded sterile products.

Sterile Products Pharmacy Technicians maintain high standard for the quality and controls of processes, components, and environments with the skill and knowledge of practices to prevent harm to patients due to 1. Microbial contamination, 2. Excessive bacterial endotoxins, 3. Variability in the intended strength of correct ingredients 4. Unintended chemical and physical contaminants, and 5. Ingredients of inappropriate quality in compounded sterile preparations (CSPs).

What you will do

• Practice
• 1. Responsible for accurately preparing patient-specific and non-patient specific doses by ensuring that the compounded sterile products (CSP) are accurately identified, measured, reconstituted, diluted, mixed, sterilized, packaged, labeled, and stored.
• CSPs are prepared aseptically, accurately, and safely in accordance to USP 797, USP 800 and CHOP Pharmacy Standard Operating Procedures (SOP)
• Only medications and ingredients with correct identity, quality and purity are used in the preparation of CSPs
• Ingredients, medications and CSPs are appropriately stored to preserve the sterility and strength until the manufacturer expiration date or CHOP assigned beyond-use date (BUD)
• Equipment, devices, and fixtures are routinely cleaned, appropriately maintained, and used for accuracy and effectiveness for their intended use as per CHOP SOP
• Ensure floors are free of debris and dust. Floors, sink, and all surfaces are cleaned daily as per CHOP SOP
• Labels products with proper information and appropriately assigns the BUD as per CHOP SOP
• Prior to dispensing, ensures all prepared CSPs are verified by a pharmacist for accurate identity, measure, reconstitution, dilution, mixture sterility, packaging, labeling, and storage at the recommended temperature.
• CSPs are prepared within allotted cycle times to ensure that the turnaround time for all first-doses and non-STAT medication orders does not exceed 1 hour and the turnaround time for all STAT medication orders does not exceed 15 minutes
• 2. Responsible for compliance to all federal, state, and department standards and regulations for sterile product compounding- USP797, USP800, CMS Conditions of Participation, FDA Compounding Guidance and TJC standards
• Completes initial aseptic technique training and passes competency test
• Reviews all CHOP Pharmacy SOPs related to CSP preparation and practices
• Completes electronic competency with score 90%
• CSP microbial contamination risk levels
• Beyond Use Dating
• Environmental Quality and Control
• ISO Class Air Sources, Buffer Area and Ante Area
• Personnel Cleaning and Garbing (Non-Hazardous and Hazardous)
• Cleaning/Disinfection Procedures (Non-Hazardous and Hazardous)
• Complete three consecutive cycles of Non- Hazardous and Hazardous PPE donning/doffing with zero (0) standard work variances including three gloved fingertip test samples with zero (0 CFU) growth results after a 3 day incubation
• Completion of aseptic media fill practical evaluation with zero (0) standard work variances including test media samples with zero (0) CFU growth results after a 14 day incubation
• Completes annual/semi-annual aseptic technique recertification and passes competency test
• Completes electronic competency with score 90%
• Completes one cycle of Hazardous and Non- Hazardous PPE donning/doffing with zero (0) standard work variances including one gloved fingertip test samples with zero (0 CFU) growth results after a 3 day incubation
• Completion of aseptic media fill practical evaluation with zero (0) standard work variances including test media samples with zero (0) growth results after a 14 day incubation
• Compliant to all dress code and PPE maintenance and associated CHOP Pharmacy SOPs
• No make-up or head/neck/wrist jewelry can be worn
• Appropriate attire in Sterile Product areas
• Scrub sets
• Short-sleeved, collarless shirts
• Full-length pants
• Skirt or dress - NOTE: Stockings/hose MUST be worn with skirt or dress
• Socks covering above ankle
• Compliant to all aseptic technique work practices and associated CHOP Pharmacy SOPs
• Cleaning, disinfection, and sanitization of laminar air flow hood (LAFH), equipment, and room at frequency defined USP 797 and CHOP SOPs
• Cleaning all products and supplies with sporicidal cleaning/disinfecting agent prior to introduction across line of demarcation
• Sanitizing all products and supplies with sterile 70% isopropyl alcohol prior to introduction into LAFH
• Sanitizing gloves with 70% isopropyl alcohol prior to introduction into LAFH for dose preparation
• Maintenance of "first air" to all critical sites during dose preparation
• Maintain all required documentation for clean room operations including but not limited to:
• Daily LAFH and work surface cleaning
• Weekly sporicidal LAFH and work surface cleaning
• Monthly sporicidal zone cleaning and inspection
• Daily air pressure differential monitoring
• Weekly eye wash hose functionality
• 3. Execute Patient Specific Daily Batch SVP Production as per CHOP Pharmacy SOP
• 4. Execute Medication Delivery and Medication Cassette Exchange as per CHOP Pharmacy SOP
• 5.Execute RIVA Batch Production as per CHOP Pharmacy SOP
• 6. Pharmacy products are distributed accurately, with the appropriate quantity and at the time the product is needed during hourly medication delivery and Bin Exchange.
• 7. Inventory Control
• Kanban Inventory system is adhered to 100% of time.
• Maintains and organizes inventory supply in a manner which minimizes inventory storage cost, wastage, and stock-outs. Ensures inventory is rotated properly, stored in appropriate conditions and location with 100% accuracy.
• Complete monthly medication expiration dating assignments in a timely manner. Identify and reorder expired medications inventory and ensures that stock is stored in accordance with manufacturer requirements.
• Assures the proper replacement of prescription drugs to stock upon requisitions from various departments of the hospital either manually or through the Pyxis System.
• 8. Ensures the secure storage of narcotics and other controlled substances.
• Documents every transaction completely and accurately.
• No generation of discrepancies in the C2 Safe, Pyxis Medstation, or Inventory Logs.
• Ensures the destruction of returned controlled substance continuous medication infusions.
• Ensures secure storage of narcotics and other controlled substances on a regular basis. Maintains inventory records on narcotics and other forms of drugs as required by law.
• Performs inventory counts of controlled substances on safes as per policy and procedures.
• 9. Achieve patient safety and satisfaction through the use of LEAN principles:
• 5S
• Elimination of Waste
• JIT
• Stand Work
• Quality
• Promotes and Complies with Standardized Procedures.
• Promotes and Complies with Standard Work.
• Identifies "waste" in ownership process and recommends solutions for implementation.
• Corrects abnormal conditions.
• 10. Participates in hospital and departmental Continuous Quality Improvement (CQI) activities.
• Utilizes LEAN Principals to analyze and resolve problems in a systematic manner.
• All improvement must be made in accordance with the scientific method
• Participation in departmental RPI
• Works OT to allow coworkers to participate in department RPI

Education Qualifications

• High School Diploma / GED - Required
• Technical Diploma Pharmacy Technician Program - Preferred

Experience Qualifications

• Sterile products compounding - Preferred

Skills and Abilities

• Basic computer skills including use of Windows operating system and word processors
• Calculation skills

Licenses and Certifications

• Certified Pharmacy Technician (CPhT) - Pharmacy Technician Certification Board (PTCB) - upon hire - Preferred or
• Certified Pharmacy Technician (CPhT) - National Association for Health Professionals (NAHP) - upon hire - Preferred

To carry out its mission, CHOP is committed to supporting the health of our patients, families, workforce, and global community. As a condition of employment, CHOP employees who work in patient care buildings or who have patient facing responsibilities must be fully vaccinated against COVID-19 and receive an annual influenza vaccine. Learn more.

Employees may request exemptions for valid religious and medical reasons. Start dates may be delayed until candidates are immunized or exemption requests are reviewed.

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