LOWER MAINLAND PHARMACY SERVICES
Page 1 of 13
POLICY TITLE
STERILE COMPOUNDING – HAND HYGIENE AND GARBING - LMPS
POLICY MANUAL
Pharmacy Services
AUTHORIZATION
Executive Director, Lower Mainland Pharmacy Services
DATE APPROVED
DATE(S) REVISED
15 Mar 2016
BACKGROUND
Proper hand hygiene and garbing are an essential part of the sterile compounding process to
prevent patient harm from contaminated compounded sterile preparations and protect staff from
drug and chemical exposure.
PURPOSE
To establish standard processes and outline requirements for hand hygiene and garbing for
personnel working in or entering controlled work areas, in accordance with provincial legislation
and standards.
FOCUS
This policy applies to all Pharmacy or non-pharmacy personnel accessing controlled work areas
located within Lower Mainland Pharmacy Services.
DEFINITIONS 2,3,4
Anteroom: An area ISO Class 7 or 8 area where personnel hand hygiene and garbing
procedures, staging of components, order entry, compounded sterile product labeling, and other
high-particulate-generating activities are performed. It is also a transition area that (1) provides
assurance that pressure relationships are constantly maintained so that air flows from clean to
dirty areas and (2) reduces the need for the heating, ventilating, and air-conditioning (HVAC)
control system to respond to large disturbances.
Cleanroom: An enclosed, ISO Class 7 area where the primary clean air device (e.g. cabinet,
isolator, workbench, hood) is physically located.
Compounded sterile preparation (CSP): A preparation intended to be sterile that is created by
combining, diluting, pooling, or otherwise altering a drug product or bulk drug substance.
Controlled work areas: includes anteroom, cleanroom, and segregated compounding area
ISO Class: An air quality classification from the International Organization for Standardization.
Portions of this information are proprietary to, and subject to copyright ownership of, Clinical IQ, LLC and have been modified by
Lower Mainland Pharmacy Services under license and for limited, internal use.
LOWER MAINLAND PHARMACY SERVICES
Page 2 of 13
POLICY TITLE
STERILE COMPOUNDING – HAND HYGIENE AND GARBING - LMPS
POLICY MANUAL
Pharmacy Services
AUTHORIZATION
Executive Director, Lower Mainland Pharmacy Services
DATE APPROVED
DATE(S) REVISED
15 Mar 2016
Line of demarcation: A line, real or virtual, that separates the anteroom or segregated
compounding area into two spaces. The “dirty” side of the line of demarcation is located at the
entrance to the anteroom, in the section adjacent to the pharmacy. The “clean” side of the line is
adjacent to the dirty area on one side and the cleanroom on the other. It is important to take
these “clean” and “dirty” areas into account when traversing the anteroom and when donning
and removing personal protective equipment.
Personal Protective Equipment (PPE): Equipment or clothing worn to minimize exposure to
chemical hazards in the workplace, enable compliance with the expected specifications of a
controlled environment and minimize potential contamination of CSPs.
Primary clean air device: A device (e.g. cabinet, isolator, workbench, hood) that provides an
ISO Class 5 environment for exposure of critical sites during the compounding of aseptic
preparations.
Segregated compounding area: A designated, unclassified space, area, or room that contains
a primary clean air device for preparation of CSPs and is void of activities and materials that are
extraneous to sterile compounding.
POLICY
General
1.1
Only authorized personnel shall enter controlled work areas
1.2
Personnel requiring access to controlled work areas shall report to the supervisor any
illnesses or conditions that may adversely affect the safety or integrity of compounded
sterile preparations (CSPs) as a result of excessive skin shedding or infectiousness
1.2.1 Such illnesses or conditions include but are not limited to the following:
 Fever
 Moderate to severe sunburn with skin sloughing
 Visible or exposed eczema or other severe skin rash
 Cough, runny nose or active respiratory infection
 Conjunctivitis
 Open wounds or weeping sores, including recent tattoos
 Other active communicable diseases
Portions of this information are proprietary to, and subject to copyright ownership of, Clinical IQ, LLC and have been modified by
Lower Mainland Pharmacy Services under license and for limited, internal use.
LOWER MAINLAND PHARMACY SERVICES
Page 3 of 13
POLICY TITLE
STERILE COMPOUNDING – HAND HYGIENE AND GARBING - LMPS
POLICY MANUAL
Pharmacy Services
AUTHORIZATION
Executive Director, Lower Mainland Pharmacy Services
1.2.2
DATE APPROVED
DATE(S) REVISED
15 Mar 2016
The supervisor shall exclude affected personnel from accessing the controlled
work area until the illness or condition is remedied or the potential impact on CSP
safety and integrity has abated
1.3
Personnel accessing controlled work areas shall pay particular attention to personal
hygiene which can affect CSP quality and the health and safety of patients
1.3.1 Nails shall be clean and trimmed
1.4
While working in or accessing controlled work areas, personnel shall comply with hand
hygiene and garb requirements as outlined in the procedures
1.4.1 Applicable hand hygiene and garbing shall be performed each time personnel
enter and leave the anteroom, cleanroom or segregated compounding area.
1.5
No food or drink, including chewing gum, candy or lozenges, shall be brought into,
stored or consumed in controlled work areas
Orientation
1.6
All personnel who enter controlled work areas shall receive orientation and successfully
complete a hand hygiene and garbing competency assessment, prior to entering the
controlled work area (See Appendix A)
1.6.1 The hand hygiene and garbing competency assessment shall be completed
annually
1.7
Personnel who have not received orientation or have not completed the competency
assessment may access controlled work areas, only under the following circumstances:
1.7.1 Must be accompanied by an oriented and qualified staff member, and
1.7.2 Must be assisted through the complete hand hygiene and garbing process by an
oriented and qualified staff member
Personal Apparel
1.8
While working in or accessing controlled work areas, personnel shall not be permitted to
wear the following:
 personal outer garments (e.g., bandanas, coats, hats, jackets, scarves,
sweaters, vests)
Portions of this information are proprietary to, and subject to copyright ownership of, Clinical IQ, LLC and have been modified by
Lower Mainland Pharmacy Services under license and for limited, internal use.
LOWER MAINLAND PHARMACY SERVICES
Page 4 of 13
POLICY TITLE
STERILE COMPOUNDING – HAND HYGIENE AND GARBING - LMPS
POLICY MANUAL
Pharmacy Services
AUTHORIZATION
Executive Director, Lower Mainland Pharmacy Services




DATE APPROVED
DATE(S) REVISED
15 Mar 2016
all leave-in hair products (e.g. hairspray, mousse, gel) and facial cosmetics
as they shed flakes and particles (exception: non-tinted skin and lip
moisturizers)
all hand, wrist, neck and head jewelry
nail polish and artificial nails or nail tips
eyelash enhancements
1.9
While working in or accessing controlled work areas, personnel are permitted to wear
the following:
 Eyeglasses
 Hearing aids
 Medical information, secured under the neckline of garb
 ID badges, secured under garb (lanyards are not permitted)
 Short sleeved undershirt, worn under garb
1.10
Personal electronic devices, including cell phones, music players and ear buds shall not
be permitted inside controlled work areas, even when contained within a pocket
Garb
1.11
While accessing controlled work areas, all personnel shall wear:
 Clean, low-shedding apparel
 Clean footwear in good condition, completely enclosing the foot from heel to toe,
including covering the top side of the foot
 Socks or stockings covering the ankles, so that skin below the hem of the garb
(scrubs) is completely covered
1.12
All personnel accessing controlled work areas beyond the line of demarcation (i.e. clean
side of anteroom or segregated compounding area, cleanroom) shall wear fresh,
dedicated, low-shedding apparel (i.e. scrubs) for each shift
1.12.1 A fastened lab coat or gown shall be worn over the apparel upon exiting the
controlled work area if personnel intend to reenter the controlled work area
wearing the same apparel.
1.12.2 Gowns worn outside controlled work areas may not be reused upon reentering
controlled work areas.
Portions of this information are proprietary to, and subject to copyright ownership of, Clinical IQ, LLC and have been modified by
Lower Mainland Pharmacy Services under license and for limited, internal use.
LOWER MAINLAND PHARMACY SERVICES
Page 5 of 13
POLICY TITLE
STERILE COMPOUNDING – HAND HYGIENE AND GARBING - LMPS
POLICY MANUAL
Pharmacy Services
AUTHORIZATION
Executive Director, Lower Mainland Pharmacy Services
DATE APPROVED
DATE(S) REVISED
15 Mar 2016
1.13
All personnel shall wear disposable or re-usable gowns in cleanrooms
1.13.1 For hazardous drug compounding, only LMPS-approved disposable gowns
resistant to fluid permeation shall be worn
1.14
Scrubs and re-usable gowns shall be
1.14.1 Supplied by the hospital,
1.14.2 Stored on site, and
1.14.3 Laundered by the hospital laundry service
1.15
Eye-shields, in the form of goggles, are required for personnel performing an activity that
has a high likelihood of splashing harmful substances such as cleaning products or
hazardous materials
1.15.1 Such activities include preparation of cleaning solutions, cleaning of controlled
work area ceilings and walls, cleaning or decontamination of the Biological Safety
Cabinet (BSC) with the viewing window raised, or cleaning up a hazardous drug
spill outside the BSC
1.16
A NIOSH-certified elastomeric or N95 respirator, fit-tested annually, shall be worn when
cleaning or decontaminating the BSC with the viewing window raised, or when cleaning
hazardous spills outside the BSC
Gloves
1.17
All Pharmacy Services personnel preparing CSPs shall wear sterile gloves
1.17.1 Pharmacy Services personnel preparing drugs in the hazardous drug Biological
Safety Cabinet shall wear two sets of sterile LMPS-approved chemotherapy
gloves, with the inner pair worn under the gown cuff and the outer pair worn over
the gown cuff
1.17.2 Sterile gloves shall be worn over the isolator gloves inside the main chamber of
an isolator
1.18
Personnel entering the cleanroom to perform tasks other than compounding, including
observation, final verification of CSPs, cleaning areas other than the interior of the
primary clean air device, and maintenance of equipment, may wear single-use nonsterile gloves donned after aseptic hand washing
Portions of this information are proprietary to, and subject to copyright ownership of, Clinical IQ, LLC and have been modified by
Lower Mainland Pharmacy Services under license and for limited, internal use.
LOWER MAINLAND PHARMACY SERVICES
Page 6 of 13
POLICY TITLE
STERILE COMPOUNDING – HAND HYGIENE AND GARBING - LMPS
POLICY MANUAL
Pharmacy Services
AUTHORIZATION
DATE APPROVED
Executive Director, Lower Mainland Pharmacy Services
DATE(S) REVISED
15 Mar 2016
1.18.1 The non-sterile gloves must be disinfected with sterile 70% isopropyl alcohol
(sIPA) after donning
1.18.2 Non-sterile gloves worn in the hazardous drug cleanroom must be
chemotherapy-approved
PROCEDURE
Personnel must don garb and perform hand hygiene in an order that proceeds from the dirtiest
to cleanest body parts, top to bottom (head and face, feet), and takes into account the location
of the line of demarcation in the facility. Each site will establish a specific order and location for
hand hygiene and garbing activities.
Prior to Entering the Anteroom or Segregated Compounding Area
2.1
Remove outer garments, jewelry, cosmetics
2.2
Don clean, low-shedding clothing (e.g. scrubs)
2.3
Perform routine hand hygiene (i.e. non surgical) using soap and water or alcohol based
hand rub
2.4
If worn, clean eyeglasses with a low-shedding single-use cloth and eyeglass cleaning
solution, sterile 70% isopropyl alcohol (sIPA), soap and water or other disinfectant
compatible with eyeglass materials
In Anteroom or Upon Entry to Segregated Compounding Area
Don Garb
2.5
Don head cover and beard cover, if required, ensuring all hair and ears are covered
2.6
Don surgical or respirator mask, ensuring coverage from the bridge of the nose to the area
under the chin
2.7
Don shoe covers one at a time, or don clean shoes dedicated to the clean side of the
ante-area and cleanroom only while stepping over the line of demarcation
Portions of this information are proprietary to, and subject to copyright ownership of, Clinical IQ, LLC and have been modified by
Lower Mainland Pharmacy Services under license and for limited, internal use.
LOWER MAINLAND PHARMACY SERVICES
Page 7 of 13
POLICY TITLE
STERILE COMPOUNDING – HAND HYGIENE AND GARBING - LMPS
POLICY MANUAL
Pharmacy Services
AUTHORIZATION
Executive Director, Lower Mainland Pharmacy Services
2.7.1
2.7.2
2.7.3
DATE APPROVED
DATE(S) REVISED
15 Mar 2016
A second pair of shoe covers should be donned if entering the hazardous
cleanroom to minimize hazardous drug contamination of controlled work areas.
The second pair can be donned while crossing the line of demarcation or on the
clean side of the anteroom. The second pair should be removed immediately
before or after exiting the hazardous drug cleanroom.
Exception: A single pair of shoe covers is sufficient if the location of the line of
demarcation results in both pairs of shoe covers being removed in the same
location
Shoe covers are single use and are not to be worn beyond the line of
demarcation
If used, dedicated shoes must be cleaned and disinfected weekly
Perform Hand Hygiene
2.8
Wash hands and forearms up to the elbow for 30 to 60 seconds with neutral soap and
water, ensuring lather is produced
2.8.1
Measure minimum of 30 seconds by referring to the second hand of a clock or
other objective means
2.8.2
Clean nails with a disposable nail pick once each shift, during the first time that
hand hygiene is performed
2.8.3
Note: Use of nail and hand brushes is not recommended as they have been
shown to cause micro-abrasions of the skin
2.9
Rinse thoroughly under running water
2.10 Dry hands and forearms thoroughly by patting with a low-shedding, single-use cloth
2.11 Turn off the water taps with the cloth and discard cloth, unless using a hands-free sink.
2.12 Notify supervisor if suffering from allergies or sensitivities to standard hand hygiene
agents
2.12.1 Consultation with Workplace Health and Infection Control will help determine an
acceptable alternative solution
Portions of this information are proprietary to, and subject to copyright ownership of, Clinical IQ, LLC and have been modified by
Lower Mainland Pharmacy Services under license and for limited, internal use.
LOWER MAINLAND PHARMACY SERVICES
Page 8 of 13
POLICY TITLE
STERILE COMPOUNDING – HAND HYGIENE AND GARBING - LMPS
POLICY MANUAL
Pharmacy Services
AUTHORIZATION
Executive Director, Lower Mainland Pharmacy Services
DATE APPROVED
DATE(S) REVISED
15 Mar 2016
Gown
2.13 Don a disposable or reusable gown that closes at the neck and has elastic cuffs. Push
sleeves of gown up to prepare for application of alcohol-based hand rub.
2.13.1 For hazardous drugs, don an approved disposable gown that resists permeability
On Clean Side of Anteroom or Upon Entry to the Cleanroom
Gloving
2.14 Open the outer wrapper of the sterile glove package onto a clean surface, exposing the
inner glove package (may occur prior to hand hygiene)
2.15 Apply alcohol-based hand rub (ABHR) with persistent activity to fingertips and all surfaces
of forearms, lower gown sleeves, then apply ABHR to hands and fingers as per
manufacturer’s recommendations
2.15.1 Alternatively, apply ABHR with persistent activity to fingertips and all surfaces of
forearms, then don gown and reapply ABHR to hands and fingers as per
ABHR manufacturer’s recommendations
2.16 Allow hands to dry completely
2.17 Don sterile gloves
2.17.1 Don the first glove with an ungloved hand by grabbing an inner surface of the
glove, and sliding the hand into it and pulling it on
2.17.2 Don the second glove by slipping the sterile gloved hand into the cuff of the
second and placing the ungloved hand into the free glove.
2.17.3 Inspect both gloves for damage and replace if any defects (tears, holes and rips)
are noted
2.17.4 Ensure gloves cover cuffs of gown
2.17.5 Gloves should be the last item donned before compounding begins
2.17.6 When using an isolator to compound, don the sterile gloves over the isolator
gloves rather than donning the sterile gloves in the anteroom area
2.17.7 Don two pairs of sterile chemotherapy gloves for hazardous drug compounding.
The cuff of the first pair goes under the gown cuff, and the cuff of the second pair
goes over the gown cuff.
Portions of this information are proprietary to, and subject to copyright ownership of, Clinical IQ, LLC and have been modified by
Lower Mainland Pharmacy Services under license and for limited, internal use.
LOWER MAINLAND PHARMACY SERVICES
Page 9 of 13
POLICY TITLE
STERILE COMPOUNDING – HAND HYGIENE AND GARBING - LMPS
POLICY MANUAL
Pharmacy Services
AUTHORIZATION
Executive Director, Lower Mainland Pharmacy Services
2.18
DATE APPROVED
DATE(S) REVISED
15 Mar 2016
Sanitize all surfaces of gloved hands with sterile 70% isopropyl alcohol (sIPA)
2.18.1 Apply sIPA to gloved hands and rub hands together to completely coat surfaces
of gloves
2.18.2 Allow sIPA to dry completely
Change Gloves
2.19
Change gloves:
2.19.1 Every hour when preparing non-hazardous drugs
2.19.2 Every 30 minutes when preparing hazardous drugs (both pairs)
2.19.3 If tearing or a puncture, or contamination with hazardous drug occurs
Repeat Hand Hygiene
2.20
Repeat full hand hygiene between glove changes
2.20.1 Exception: Hands that are not visibly soiled may be cleansed with alcohol-based
hand rub with persistent activity as per manufacturer’s recommendations when
performing non-hazardous sterile compounding
2.20.2 Always perform full hand hygiene procedures when changing gloves due to
tearing or a puncture
Disinfecting Gloves
2.21 Disinfect gloved hands with sIPA (wipe or pour onto gloves) at the following times:
2.21.1 Prior to entering the primary clean air device (e.g. when placing items into the
hood)
2.21.2 Prior to commencing each new batch
2.21.3 Any time the gloved hands re-enter the primary clean air device after making
contact with non-sterile surfaces
2.21.4 Periodically, during prolonged periods of compounding within the primary clean
air device
Upon Exiting the Clean Room or Segregated Compounding Area
2.22
All PPE used for hazardous compounding must be disposed of into hazardous waste
receptacles
Portions of this information are proprietary to, and subject to copyright ownership of, Clinical IQ, LLC and have been modified by
Lower Mainland Pharmacy Services under license and for limited, internal use.
LOWER MAINLAND PHARMACY SERVICES
Page 10 of 13
POLICY TITLE
STERILE COMPOUNDING – HAND HYGIENE AND GARBING - LMPS
POLICY MANUAL
Pharmacy Services
AUTHORIZATION
Executive Director, Lower Mainland Pharmacy Services
DATE APPROVED
DATE(S) REVISED
15 Mar 2016
2.23
Remove gloves and discard
2.23.1 For hazardous drug compounding, remove outer gloves inside the primary clean
air device. Alternatively, outer gloves may be cleaned with a saturated wipe
inside the primary clean air device and removed before exiting the cleanroom.
Gloves and any wipes used shall be discarded in the hazardous waste
receptacle.
2.23.2 For hazardous drug compounding, remove and dispose of inner gloves after
removal of other garb in the anteroom.
2.24
For hazardous drug compounding, remove the outer second set of shoe covers
immediately before or after exiting the hazardous drug cleanroom
2.25
Remove gown, prior to stepping over the line of demarcation into the “dirty” section of
the anteroom
2.25.1 Gown may be saved for subsequent use throughout the shift provided it is not
visibly soiled. If retained, hang on a hook in the cleanroom or on the clean side of
the anteroom. Gowns may not be shared between staff members.
2.25.2 Chemotherapy gowns must be changed every 3 hours of compounding, at
minimum
2.25.3 Chemotherapy gowns worn in the hazardous compounding cleanroom must be
removed immediately before or after exiting the cleanroom to prevent the spread
of hazardous drug contamination from one area to another
2.25.4 At the end of the session or shift, discard disposable gown into appropriate waste
container or place reusable gown in laundry
2.26
Remove remaining shoe covers, upon stepping over the line of demarcation into the dirty
section of the anteroom, and discard
2.27
Remove and discard face mask, facial hair cover, and head cover on the
“dirty side” of the anteroom or beyond the line of demarcation
2.28
Wash hands with soap and water
Portions of this information are proprietary to, and subject to copyright ownership of, Clinical IQ, LLC and have been modified by
Lower Mainland Pharmacy Services under license and for limited, internal use.
LOWER MAINLAND PHARMACY SERVICES
Page 11 of 13
POLICY TITLE
STERILE COMPOUNDING – HAND HYGIENE AND GARBING - LMPS
POLICY MANUAL
Pharmacy Services
AUTHORIZATION
Executive Director, Lower Mainland Pharmacy Services
DATE APPROVED
DATE(S) REVISED
15 Mar 2016
REFERENCES
1. BCCA Pharmacy Practice Standards for Hazardous Drugs. BC Cancer Agency, 2015.
Available from http://www.bccancer.bc.ca/health-professionals/professionalresources/pharmacy/safe-handling-manual
2. Compounding: Guidelines for Pharmacies. Canadian Society of Hospital Pharmacists,
Ottawa, Ontario, 2014. www.cshp.ca
3. Model Standards for Pharmacy Compounding of Non-hazardous Sterile Products. National
Association of Pharmacy Regulatory Authorities, 2015. www.napra.ca
4. United States Pharmacopeia, General Chapter <797>: Pharmaceutical compounding – sterile
preparations. USP 39, Rockville, MD, 2016. www.usp.org
5. United States Pharmacopeia, General Chapter <800>: Hazardous Drugs – handling in
healthcare settings. USP 39, Rockville, MD, 2016. www.usp.org
Portions of this information are proprietary to, and subject to copyright ownership of, Clinical IQ, LLC and have been modified by
Lower Mainland Pharmacy Services under license and for limited, internal use.
LOWER MAINLAND PHARMACY SERVICES
Appendix A
Page 12 of 13
Hand Hygiene and Garbing Competency Assessment
Date of Evaluation:_________________________
Employee Name: ________________________
Position Title:
Evaluator Name: ________________________
Evaluator Position:
Type: ___ Initial Competency ___ Ongoing Competency ___ Other:
Observations and evaluations must be made by qualified pharmacy staff. In the “RATING” column, the evaluator will note the
following: S=satisfactory competency, U= unmet competency, N/A = not applicable, N/O= not observed
Additional comment is required if any notations of U, N/A or N/O, with a specific plan to correct noted in the Remedial Plan section.
SKILL
RATING
COMMENTS
Presents in a clean appropriate attire. Removes extraneous
personal clothing (scarves, vests, sweaters, hats, etc) and
wears clothing that is consistent with established policy
Wears no cosmetics or jewelry (watches, rings, earrings,
piercings visible prior to garbing) upon entry into ante-area.
Neither brings nor stores food, drink or personal electronic
device in the controlled work areas.
Nails are not excessively long, no artificial nails
Wears appropriate shoes and socks covering ankles
Changes into clean, low-shedding apparel i.e. scrubs
Cleans eyeglasses, if worn
Performs routine hand hygiene (soap + water or regular
alcohol-based hand rub) prior to entering controlled work areas
Demonstrates awareness of and performs garbing activities on
correct side of the line of demarcation.
Dons head cover, assures all hair covered using mirror to verify
Dons face mask to cover bridge of nose down to base of chin
Optional: Dons beard cover if necessary.
Optional: Puts on safety goggles, if required.
Dons shoe covers or designated clean shoes one at a time,
placing the covered or designated shoe on the clean side of the
line of demarcation as appropriate. Dons 2 pairs of shoe covers
for hazardous drug compounding.
Wets hands and forearms, washes using soap and water for at
least 30 seconds during which nails are cleaned with
disposable nail pick.
Dries hands and forearms by patting with low-linting towel.
Dons gown and ensures full closure. Gown may be reusable or
disposable for non-hazardous compounding, but must be
impervious and disposable for hazardous compounding.
Portions of this information are proprietary to, and subject to copyright ownership of, Clinical IQ, LLC and have been modified by
Lower Mainland Pharmacy Services under license and for limited, internal use.
LOWER MAINLAND PHARMACY SERVICES
Appendix A
Page 13 of 13
SKILL
RATING
COMMENTS
Disinfects hands again using a waterless alcohol-based
surgical hand rub with persistent activity and allows hands to
dry thoroughly before donning sterile gloves.
Dons appropriate-sized sterile gloves. Dons 2 sets of gloves for
hazardous compounding (under and over gown cuffs).
Examines gloves ensuring that there are no defects or holes
Routinely disinfects gloves with sterile 70% IPA prior to entering
PCAD, routinely during compounding and after touching items
or surfaces outside the PCAD
Change gloves every hour during non-hazardous and every 30
minutes during hazardous drug compounding
Performs hand hygiene between glove changes (ABHR or full
hand hygiene for non-hazardous compounding or full hand
hygiene for hazardous compounding)
Removes gloves at end of compounding session. For
hazardous drug compounding, removes outer gloves inside
PCAD or wipes gloves in PCAD and removes outer pair in
cleanroom. Removes inner pair after removing other hazardous
compounding PPE
Removes non-hazardous gown and discards it (if finished
compounding for the day) or hangs on a hook in cleanroom or
on the clean side of the ante-area (if not visibly soiled and is
intact) where it may be reused during the same work day only
Changes hazardous gown every 3 hours. Removes gown
immediately before/after exiting hazardous drug cleanroom
For hazardous compounding, removes outer pair of shoe
covers immediately before/after exiting hazardous cleanroom.
Removes remaining shoe covers or shoes one at a time when
crossing line of demarcation, ensuring that the uncovered foot
is placed on the dirty side of the line of demarcation
Removes and discards mask, head cover and beard cover
crossing over line of demarcation
Disposes of all PPE for hazardous compounding in hazardous
waste receptacles
Washes hands with soap and water after removing garb
Remedial Action Plan/Additional Comments
Employee Signature
Date
Qualified Evaluator Signature
Date
Portions of this information are proprietary to, and subject to copyright ownership of, Clinical IQ, LLC and have been modified by
Lower Mainland Pharmacy Services under license and for limited, internal use.