1140-07-.07
Hazardous Products
Cite as Tenn. Comp. R. & Regs. 1140-07-.07
(1)
Physical Requirements.
(a)
If the pharmacy practice site is engaged in the compounding of hazardous sterile
products, a suitable facility to prepare such products and minimize the risk associated
with such products shall be provided.
(b)
Such pharmacy practice site shall be designed and equipped for storage and have a
procedure for disposal of materials containing hazardous residues in accordance with
state and federal laws.
(1)
A dedicated Class II, Type A contained vertical flow biohazard cabinet is the
minimally acceptable compounding site for the routine compounding of
hazardous sterile products.
STERILE PRODUCT PREPARATION IN PHARMACY PRACTICE
CHAPTER 1140-07
(2)
Hazardous sterile products shall be segregated within the pharmacy practice site
and storage areas so identified.
(2)
Dispensing.
(a)
Prepared doses of hazardous sterile products for patients shall be placed in an
appropriate outer wrap to minimize the risk exposure in case of accidental rupture of
the primary container.
(b)
Reasonable effort shall be made to assure that all hazardous sterile product primary
containers and waste are removed from the site of use and disposed of as hazardous
waste in accordance with applicable state and federal laws.
(3)
Training.
(a)
As part of the training for all pharmacists, pharmacy interns and pharmacy technicians
involved in compounding of hazardous sterile products, an annual certification must be
made by each pharmacist, pharmacy intern and pharmacy technician and the
pharmacist in charge that each has read and understands the latest editions of:
1.
Work Practice Guidelines for Personnel Dealing with Cytotoxic (Antineoplastic)
Drugs (Occupational); and
2.
The American Society of Health-System Pharmacists (ASHP) technical
assistance bulletin on handling cytotoxic and hazardous substances.
(4)
Hazardous sterile products dispensed shall bear a distinctive warning label with an
appropriate caution statement thereon.
(5)
Gloving and gowning shall be required in the compounding of hazardous sterile products.
Gloves should be rinsed frequently with a sanitizing agent (e.g., seventy percent (70%)
isopropyl alcohol) and shall be changed when the integrity of the gloves is compromised.
(6)
In the compounding of hazardous sterile products, a protective disposable gown made of
lint-free low permeability fabric with a closed front, long sleeves and elastic or knit closed
cuffs with cuffs tucked under the gloves shall be worn. Gowns and gloves used in the
compounding of hazardous sterile products shall not be worn outside the sterile product
compounding area.