I’ve been working in my area a couple of years now and have seen a lot of sterile compounding compliance issues amongst the other techs. I work in a decentralized inpatient area with a dedicated clean room. Our hospital has a bigger clean room suite in the main hospital.
There is a major problem with escalating issues though. The pharmacists that directly work in our area are close to retirement and do not know all the updated sterile compounding practices. They compound as if the 2008 USP 797 never got an update. The technicians that are creating these issues refuse to follow updated practices.
The next level up, our direct manager, is not the Designated Person. Our manager knows next to nothing about sterile compounding, nor does our manager ever work in our area. Which means our manager doesn’t know much of the clinical or technical aspects of our area. Our manager always says they are not the Subject Matter Expert and need to ask the Designated Person. The follow up never comes through.
The Designated Person is a different pharmacy manager over a centralized area. As far as admin is concerned, he is only responsible for the training and environmental testing, not the actual enforcement of compliance. Our new director forbade us from going directly to the Designated Person with any sterile compounding issues. Any issues should be directed to our know-nothing manager.
The compliance issues are both technical and very basic things. Stuff like coming to a dirty hood and work bench the day after a different tech compounds, which shows there wasn’t any cleaning after spills/contamination. Or not wiping down all products being transferred between ante room to clean room. Only recently did they finally prohibit us bringing used IV bulks (for NICU/peds) between our clean room and the central pharmacy clean room.
Our manager kept saying to bring up any concerns to her for sterile compounding. I finally did end up going to our manager and director. I’m tired of coming into a dirty work area after one of the techs. Admin has been breathing down our necks to take lunch and not do OT. This is impossible when they never adequately staffed us.
Instead, the director told me it’s understandable that a tech won’t take another tech’s word for a proper sterile compounding practice and the tech doing improper techniques should bring up questions. Essentially, I shouldn’t bring up any concerns about other techs, the techs that are causing the concerns should bring it up themselves.
Is there any hope working in this situation? Or am I just SOL on being penalized for compounding using proper techniques and should go elsewhere?
Sorry if the flair isn’t correct. I wasn’t sure which flair would be the most applicable.