HospitalInspections.org

Based on record review and interview, the pharmacist failed to ensure 2 of 6 pharmacy staff had annual competencies in sterile product compounding. The hospital is required to develop and monitor pharmacy procedures to ensure patient safety.

The findings included:

Review of the hospital policy "Competency Assessment" (effective July 2015) revealed, "All pharmacy personal will submit to a preliminary assessment of their basic competency as soon as possible after their initial employment date....The director will assess all staff initially and annually thereafter."

Review of the hospital form "Sterile Product Compounding Assessment" revealed, "to be completed at hire, annually, and any time warranted." The form showed Pharmacist Technician Staff A was last assessed on 3/30/16. There was no further documentation of competency for Staff A.

Another hospital form titled "Compounding Sterile Products Initial Training Guidelines and Documentation Checklist" directed, "All annual training requirements should be done in the month of May." The form showed Pharmacist Staff B was last assessed on 4/16/16. There was no further documentation of competency for Staff B.

In an interview on 9/20/17 at 3:10 p.m., the Director of Pharmacy confirmed Pharmacist Technicians Staff A and Staff B had not had annual competencies completed for sterile product compounding. The Director of Pharmacy said he was hired in May of 2017. He was told when he was hired that staff did not have to have do annual competencies for compounding sterile products. He acknowledged it did not sound right to him at the time because every other place he had worked the staff were required to do annual competencies.