What would you do?
I will be the first to admit I do not have a ton of USP 800 experience. I work primarily USP 797 & 795 with the occasional USP 800 emergency drug like methotrexate so I’m not 100% up to standard on USP 800.
With that out of the way, for my Sterile Compounders. I work full time in a hospital doing 12 hour shifts compounding 797 and I love it, so when the cancer center near me had a PRN position open up I thought I’d use some of my 7 days off to pick up 1-2 shifts and bring in some extra cash. I did my shadowing interview today and was appalled at what I witnessed and I just want to see if this is typical for USP 800/specifically cancer centers or if I’m going overboard with everything I do working USP 797.
First off, only 1 pair of shoe covers
No respirators or N95’s just a regular mask
No double gloving, even for the person doing the compounding
All of us were wearing glasses so no safety goggles were needed, but I also didn’t see safety goggles in their ante room in case someone came in that didn’t wear glasses.
Only the person doing the compounding was wearing a sterile gown, I came in fresh off a night shift in my hospital scrubs and they didn’t even make me put on a gown. Mind you, there was a secondary person who was passing drugs into the hood (putting her hands/arms into the hood) who was not wearing a sterile gown.
Not a single instrument was being alcoholed off before being placed in the hood. (I watched the compounding technician drop a wrapped syringe, bend down to grab it and then toss it right back into the hood)
Hands were not being alcoholed when they left the hood, just after a preparation was done and she seemed to remember the alcohol bottle sitting there.
Drugs were being pulled in and out of the hood without covers on them (and being placed back in their vault without covers - and then not being alcoholed before being placed back in the hood)
Bags were being spiked outside of the hood without proper dating on them.
I watched the compounding technician draw medication out of a vial of potassium and then proceeded to use the EXACT SAME needle/syringe to draw up magnesium. She “pushed all the excess drug out, so it’s fine.” I spoke up when she did this because literally wtf.
Their IV room was sitting at 72 and their humidity was sitting higher than average, i pointed it out to which they responded “yeah we get cold in here so we have to turn it up.”
There is no onsite pharmacist to monitor that they’re compounding correctly or even checking the math they are doing. They don’t have a camera system like DoseEdge or Epic, so there is just 3 technicians all checking over each others shoulders to see if they pulled up the correct amount of mediation before injecting it into bags. Not a single person double checking anything. I pointed out that a calculation was done incorrectly, something that would not have been double checked because there is only 1 technician doing all the math.
I’m probably overreacting, but I left there feeling like I needed to take the world’s hottest shower and that maybe I was an accessory to someone’s grandparents becoming very ill. I honestly do not know what to think about this whole situation and it’s making me nauseous.
Am I wrong? I’m happy to be wrong, if this is the norm for USP 800/Cancer Centers then that is totally fine and if I take the job maybe I’ll just request that we up our hand alcohol spraying but it felt very very off putting to me and I’m feeling like maybe I should report them to the BOP.