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Proactively investing in quality and safety

May 15, 2019
The Calgary Compounding Centre is well on its way to complying with ACP’s new non-sterile compounding standards.

The Calgary Compounding Centre (CCC) opened in 2015 when Market Mall Pharmacy and Compounding began looking at the draft standards for USP Chapter 800, which describes the practice and quality standards for preparing and handling hazardous drugs in health care settings in the United States.

“We knew that, at some point in the near future, we were probably looking at changes to standards in Alberta that we might not be able to comply with in the space we had,” said CCC co-owner and licensee Dan Curle. “We were operating with our little lab which was sectioned off in our Market Mall pharmacy. It had a powder containment hood and a door partitioning it off from the rest of the pharmacy, but we knew we needed more space.”

Dan secured space on the third floor of the Market Mall professional building, two floors up from their retail location. After a year of work to engineer a proper ventilation system, the CCC was born.

“Our lab is basically a mirror image of itself,” said Dan. “One half of it is under negative pressure and is ventilated outside, the other half is meant for other products that don’t have the same precautions.”

When ACP introduced its new non-sterile compounding standards, the CCC was ahead of the game, but Dan recognized there was still lots of work to do to comply with the deadlines for the three priorities identified in the standards, particularly with priority one—assessing risks and gaps.

“The whole assessment piece is certainly a big undertaking and we’re adding chemicals to it all the time,” said Dan. “We’re approaching this on a chemical-by-chemical basis, looking at the risk assessment of each individual product that we’re making. You need to determine if your facility provides a safe environment for each individual chemical.”

For priority two—compounding and cleaning, personnel training, and quality assurance—the CCC has implemented new compounding software to reduce risk to staff and patients and increase quality assurance.

“When we opened this new lab, one of our big goals was to provide a safe product to the patient without having to have a pharmacist go in and out of the lab all the time,” said Dan.

Under the CCC’s new workflow, every chemical that enters the lab is given a bar code which is applied to the product and checked by the pharmacist. When preparing a compound, a pharmacy technician will scan the bar code to verify the chemical. Powders are weighed and must be within a certain percentage of error before continuing with the process. Liquid volumes are verified via digital photos. At the end of the compounding process, the pharmacist can verify everything on a computer without ever having to enter the lab and risk exposure or contamination.

“This is a big step forward for us, not only in complying with the standards, but being more comfortable knowing we’re in a healthy environment,” said Dan. “We’ve also learned that, by applying the new standards, we’ve become a lot more efficient through implementing our software, separating our workflow, and having better quality assurance.”

For more on meeting your risk assessment, compounding and cleaning, personnel training, and quality assurance priorities, refer to the Getting Started document, Compounding Essentials, Compounding FAQs, and other resources found on our non-sterile compounding standards page on the ACP website.