It Takes a Team! Implementing United States Pharmacopeia (USP) General Chapter <800> Across a Healthcare System

摘要

Context: In March of 2014, USP was introduced in its draft form as a proposed set of guidelines for the safe handling of hazardous drugs. During this time UCHealth was actively seeking Quality Oncology Practice Initiative (QOPI) certification for its system Oncology Service Line including 5 hos pitals across three regions within the state. Following certification, the QOPI steering committee promptly shifted focus to the proactive preparation for USP implementation, initially scheduled for July 1, 2018 (and later delayed to December 1, 2019). Approach: Considering the impact of this initiative was beyond the specialty of oncology, a robust interdisciplinary team was recruited, utilizing Bruce Tuckmans Team Development Model. During the forming stage, initial stakeholders were identified including the specialties of pharmacy, nursing, leadership, information technology, value analysis, and supply chain within the three regions. This diverse group met routinely in person, as well as virtually. The team collaborated to interpret the USP guidelines and performed a gap analysis related to current practice differences among regions in addition to compliance with the guidelines. Extensive planning surrounding implementation of the program took place requiring the formation of subcommittees of subject matter experts. Results: Several key changes were implemented to ensure compliance. Stakeholders from several specialties took part in the development of a Safe Handling of Hazardous Drugs (HD) policy, as well as creation of an HD personal protective equipment (PPE) charts. These outline recommended PPE as determined by the HD class, route, and specific exposure (medication administration vs. contact of contaminated bodily fluids). A computer-based training module was chosen as the method of education. This was designed and disseminated to all staff with risk of potential contact with hazardous drugs or contaminated bodily fluids. Changes to medication labeling were standardized for all hazardous drug (HD) dispensing pharmacies. Several closed-system transfer devices (CTSD) were researched and a standard product was selected for use throughout the UCHealth system. Standardized door signage for easy identification of patients on HDs was also created. Summary: Aligning with Tuckmans performing and adjourning stages, the dedication of this dynamic interdisciplinary team to collaboration and prioritization of the safety of staff members successfully led to a multifaceted approach to compliance with USP guidelines. UCHealth has instituted this program at an additional 8 facilities it has since acquired. Applications: Recently there was a detailed review and revision of the policy, in addition to a taskforce developing ongoing annual competency training for staff. The next phase of this project is the consideration of medical surveillance of staff as encouraged by the USP guidelines. Innovation: When USP proposed a set of robust guidelines to enact for the safety of healthcare workers, UCHealth prioritized this initiative, taking a proactive and progressive approach to prepare for implementation, even when other large health systems across the nation were just beginning. This included the congregation and focused collaboration of a widespread, but dynamic team that spanned several facilities and regions to produce a successful program.