Portage pharmacy certified to meet new requirements

Kali Katerberg/Daily Mining Gazette The UP Health Systems - Portage hospital pharmacy isolator in use compounding non-hazardous materials.

HANCOCK — New state IV medication preparation requirements are in effect, and with hospitals around the state pushing to get certification, the UP Health Systems – Portage hospital pharmacy has joined those that are certified.

Hospitals typically contain internal pharmacies that prepare medication for patients on-site in a process called compounding. The state is now requiring these pharmacies meet and be certified for United States Pharmacopeia (USP) sterile compounding requirements.

The idea is to ensure no contaminants are introduced into IV medications when sterile ingredients are combined, ensuring the end product is sterile.

The USP sets standards for quality and purity and is both nonprofit and nongovernmental. Michigan is one of the last states to require the licensing.

Licensing has resulted changes to hospital practices, but at Portage the changes were minimal, said Tracey Bershing, director of Inpatient Pharmacy.

Kali Katerberg/Daily Mining Gazette The UP Health Systems - Portage hospital pharmacy isolator in use compounding non-hazardous materials.

“We have been doing that (sterile compounding) for many many years, but now you have to become certified or accredited or have an inspection to say that you actually meet these guidelines,” she said. “It’s not that we haven’t been doing them, because we’ve been doing them for 20 years. It’s just that we need to have someone come in and say, you’re doing what you have to be doing.”

Quite a bit of compounding is done in the pharmacy for the rest of the hospital, including the Emergency Department, surgical, post-surgical, obstetric (OB) ward and cancer care infusion center.

“We’re preparing all of those IV medications, and we do quite a bit,” Bershing explained. The medications are all used internally.

The compounding process takes place within two specific pressurized rooms in the pharmacy, with one only accessible from the first room. Larger hospitals often have three, but that’s more difficult for rural hospitals like Portage.

Non-hazardous preparations are done in an isolator, or “glove box” in the first room, while hazardous chemical compounding, often for cancer treatments, is done in the other, where pharmacists are covered from head to toe.

“We had to do a couple of structural changes, but really not much because we were already doing most of it,” Bershing said.

Changes included adding a cleaning agent for spores along with those for germs, adding an extra sink, upgrading pressure monitors for ones with an extra decibel and swapping out a wooden door.

“The amount of work behind the scenes …to make sure the products we’re providing are safe for our patients, our community, our friends and family. That’s what we’re here to do,” she said.

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