Assessor Resource

HLTPHA007
Conduct small-scale compounding and labelling of aseptic pharmaceutical products

Assessment tool

Version 1.0
Issue Date: April 2024


This unit describes the skills and knowledge required to complete small scale compounding of sterile pharmaceutical products from pre-determined formulae, including extemporaneous dispensing. This includes cytotoxic and total parental nutrition (TPN) products.

This unit applies to pharmacy assistants and technicians working under the supervision of a pharmacist.

The skills in this unit must be applied in accordance with Commonwealth and State/Territory legislation, Australian/New Zealand standards and industry codes of practice

You may want to include more information here about the target group and the purpose of the assessments (eg formative, summative, recognition)



Evidence Required

List the assessment methods to be used and the context and resources required for assessment. Copy and paste the relevant sections from the evidence guide below and then re-write these in plain English.

ELEMENT

PERFORMANCE CRITERIA

Elements define the essential outcomes

Performance criteria describe the performance needed to demonstrate achievement of the element

1. Source informationon formula

1.1 Select appropriate formula and master work sheet for the product, based on correct interpretation of the prescription or medication order

1.2 Confirm suitability of chosen master work sheet and availability of resources

1.3 Obtain authority of pharmacist to proceed

2. Prepare for production process

2.1 Confirm the availability of the appropriate laminar flow hood/clean room or cytotoxic drug safety cabinet/cytotoxic suite or room or isolator required to compound the product according to the work sheet

2.2 Comply with dress code, safety and personal hygiene procedures prior to entering the work area

2.3 Clean work area and equipment correctly

2.4 Maintain inventory levels of materials and disposable equipment

2.5 Prepare a work sheet referenced from amaster work sheet

2.6 Assign product batch number

2.7 Verify that the work sheets are clearly written in logical order with clear directions and contain all the required information

2.8 Generate the product labels referenced from the master label detailed on the master work sheet

2.9 Check and note the number of labels generated

2.10 Submit work sheet and labels to pharmacist for approval

2.11 Check and set up compounding requirements and disposable equipment

3. Obtain equipment and supplies

3.1 Assemble materials used in aseptic compounding as listed in the work sheet, according to stock levels and stock requisitioning procedures

3.2 Check materials to ensure they have been released from quarantine for use by authorised persons

3.3 Verify materials against manufacturing work sheet and record material batch numbers and expiry dates

3.4 Select appropriate types, size and features of containers and packaging listed in the work sheet

3.5 Weigh or measure materials in designated area

3.6 Obtain required authorisation or checks at designated points according to the work sheet

4. Prepare for sterile manufacturing

4.1 Transfer raw materials, disposable equipment, required containers or packaging and covered work sheet to pre-production area

4.2 Follow hand washing, gowning and gloving procedures

4.3 Disinfect and transfer materials, disposable equipment and work sheet to sterile production area

5. Prepare for cytotoxic production

5.1 Check that cytotoxic spill cleaning kits are available in all production areas

5.2 Select and use appropriate sterile personal protective equipment for safe handling and preparation of cytotoxic drugs as required

5.3 Follow specific procedures to minimise risk of exposure to cytotoxic drugs

6. Compound products using aseptic techniques

6.1 Allocate approved bulk materials, intermediary products and containers to appropriate equipment

6.2 Incorporate materials according to work sheet using appropriate manipulation technique

6.3 Compound product according to method on manufacturing work sheet

6.4 Prepare cytotoxic products using procedures for safe handling of cytotoxic drugs

6.5 Operate specialist equipment and use specialist supplies in sterile production preparation

6.6 Perform verification procedures and inspect finished product for deviations and report to authorised person

6.7 Pack compounded product into appropriate container as specified on the work sheet, and following approval from an authorised person

6.8 Label containers according to labelling specifications on the work sheet

6.9 Obtain required authorisation or checks at designated points

7. Complete production process

7.1 Reconcile the number of labels printed with number used and report discrepancies to the pharmacist

7.2 Place product in quarantinearea under appropriate storage conditions

7.3 Clean machinery and manufacturing area and dispose of disposable equipment safely

7.4 Follow procedures for cleaning cytotoxic spills, and exposure to cytotoxic drugs

7.5 Complete required documentation and forward to an authorised person

7.6 Report discrepancies to an authorised person

7.7 Obtain final approval from pharmacist before releasing compounded medicines to storage areas

7.8 Discard waste materials appropriately

8. Participate in quality control

8.1 Pack and label a retention sample and/or quality control sample if specified on the work sheet

8.2 Perform environmental monitoring and report abnormal readings to an authorised person

8.3 Submit product sample and relevant documentation to quality control

8.4 Record and file product quality control assay results and manufacturing area environmental monitoring results

9. Store and transport released product

9.1 Store products according to the work sheet

9.2 Obtain released product(s) from quarantine store

9.3 Pack released product(s) into delivery containers which will maintain the required ambient conditions for the product

9.4 Deliver product to destination ensuring safe transport of cytotoxic products

9.5 Advise receipting area personnel of storage requirements

9.6 Complete and file records and/or work sheets

The candidate must show evidence of the ability to complete tasks outlined in elements and performance criteria of this unit, manage tasks and manage contingencies in the context of the job role. There must be evidence that the candidate has:

followed established procedures and industry codes to accurately and safely produce 10 aseptic products:

worked within the requirements of sterile areas, air locks, laminar flow hoods and cytotoxic drug safety cabinet/isolators

identified issues outside scope of practice and referred these to the authorised person

The candidate must be able to demonstrate essential knowledge required to effectively complete tasks outlined in elements and performance criteria of this unit, manage tasks and manage contingencies in the context of the work role. This includes knowledge of:

legal and ethical requirements (national, state/territory) for pharmacy work, and how these are applied in organisations, including:

codes of conduct

duty of care (and implications of negligence)

privacy, confidentiality and disclosure

records management

rights and responsibilities of workers, employers and clients

specific legislation:

medicines and their use

the practice of pharmacy

different schedules of medicines and pharmaceutical products

work role boundaries – responsibilities and limitations in manufacturing products

work health and safety

key information in standard pharmaceutical references and their use in manufacturing, including:

Australian pharmaceutical formulary and handbook (APF)

MIMs

Australian medicines handbook (AMH)

Micromedex

rationale and key features of:

The Society of Hospital Pharmacists (SHPA) Standards of practice for the safe handling of cytotoxic drugs in pharmacy departments

Pharmaceutical Inspection Convention/Pharmaceutical Inspection Co-operation Scheme (PIC/S) Guide to good practices for the preparation of medicinal products in healthcare establishments (PE010-3)

product identification and handling, including those for:

formulary medicines and non-formulary medicines

products with the required integrity as well as those whose integrity has been compromised

routine of handling products and products requiring special handling

nature and use of different dosage forms, including:

oral

parenteral products

topical

infection control requirements for small scale compounding of aseptic pharmaceutical products, including:

aseptic technique

correct disposal of sharps and residues

cleaning and disinfection processes plus sterilisation of pharmaceuticals

personal hygiene and clothing standards

sources and types of contamination and required responses – microbial, cross-chemical, physical, environmental and corrective strategies

processes relating to aseptic, including:

calculations for all sterile admixtures

chemical and physical properties of materials in relation to formulation and compounding

principles and procedures of formulae calculations, weights and measures

principles of aseptic technique, including cytotoxic manufacturing

processes for dilution, suspension, incorporation and reconstitution

use of terminal filtration

risk considerations and procedures for pharmaceutical manufacturing:

product security

handling and storage of hazardous materials

quarantine periods

management of cytotoxic spills

specific hazards related to cytotoxic manufacture

transport of cytotoxic medications

requirements for formulated manufacturing documentation, including:

different documentation types, their scope and purpose

worksheet processes

information quality requirements (including clarity, logic and completeness)

specific labelling requirements for compounded products, including:

adherence to legislative requirements

name, form and strength of product

ancillary labels as part of label details

hazard warnings

spacing for entry of batch numbers and expiry dates

packaging methods, container materials and principles for selection

storage and transport requirements and rationale for different types of product including:

hazardous materials

special storage considerations:

humidity

isolation

light

temperature

ventilation

features and use of pharmacy systems used for aseptic compounding

circumstances that require compounding of the product within a laminar flow hood/clean room or cytotoxic drug safety cabinet/cytotoxic suite or room or isolator

Skills must have been demonstrated in the workplace or in a simulated environment that reflects workplace conditions. The following conditions must be met for this unit:

use of suitable facilities, equipment and resources, including:

simulated facilities with physically separate areas for preparation/checking of product, hand washing and manipulation of produce

gowns, gloves and hand washing facilities

weighing and measuring equipment

materials (including simulation medicine substitutes such as coloured water) and disposable equipment

note that a clean room environment is not required for simulated assessment

modelling of industry operating conditions, including time constraints for completing activity

Assessors must satisfy the Standards for Registered Training Organisations (RTOs) 2015/AQTF mandatory competency requirements for assessors.


Submission Requirements

List each assessment task's title, type (eg project, observation/demonstration, essay, assingnment, checklist) and due date here

Assessment task 1: [title]      Due date:

(add new lines for each of the assessment tasks)


Assessment Tasks

Copy and paste from the following data to produce each assessment task. Write these in plain English and spell out how, when and where the task is to be carried out, under what conditions, and what resources are needed. Include guidelines about how well the candidate has to perform a task for it to be judged satisfactory.

ELEMENT

PERFORMANCE CRITERIA

Elements define the essential outcomes

Performance criteria describe the performance needed to demonstrate achievement of the element

1. Source informationon formula

1.1 Select appropriate formula and master work sheet for the product, based on correct interpretation of the prescription or medication order

1.2 Confirm suitability of chosen master work sheet and availability of resources

1.3 Obtain authority of pharmacist to proceed

2. Prepare for production process

2.1 Confirm the availability of the appropriate laminar flow hood/clean room or cytotoxic drug safety cabinet/cytotoxic suite or room or isolator required to compound the product according to the work sheet

2.2 Comply with dress code, safety and personal hygiene procedures prior to entering the work area

2.3 Clean work area and equipment correctly

2.4 Maintain inventory levels of materials and disposable equipment

2.5 Prepare a work sheet referenced from amaster work sheet

2.6 Assign product batch number

2.7 Verify that the work sheets are clearly written in logical order with clear directions and contain all the required information

2.8 Generate the product labels referenced from the master label detailed on the master work sheet

2.9 Check and note the number of labels generated

2.10 Submit work sheet and labels to pharmacist for approval

2.11 Check and set up compounding requirements and disposable equipment

3. Obtain equipment and supplies

3.1 Assemble materials used in aseptic compounding as listed in the work sheet, according to stock levels and stock requisitioning procedures

3.2 Check materials to ensure they have been released from quarantine for use by authorised persons

3.3 Verify materials against manufacturing work sheet and record material batch numbers and expiry dates

3.4 Select appropriate types, size and features of containers and packaging listed in the work sheet

3.5 Weigh or measure materials in designated area

3.6 Obtain required authorisation or checks at designated points according to the work sheet

4. Prepare for sterile manufacturing

4.1 Transfer raw materials, disposable equipment, required containers or packaging and covered work sheet to pre-production area

4.2 Follow hand washing, gowning and gloving procedures

4.3 Disinfect and transfer materials, disposable equipment and work sheet to sterile production area

5. Prepare for cytotoxic production

5.1 Check that cytotoxic spill cleaning kits are available in all production areas

5.2 Select and use appropriate sterile personal protective equipment for safe handling and preparation of cytotoxic drugs as required

5.3 Follow specific procedures to minimise risk of exposure to cytotoxic drugs

6. Compound products using aseptic techniques

6.1 Allocate approved bulk materials, intermediary products and containers to appropriate equipment

6.2 Incorporate materials according to work sheet using appropriate manipulation technique

6.3 Compound product according to method on manufacturing work sheet

6.4 Prepare cytotoxic products using procedures for safe handling of cytotoxic drugs

6.5 Operate specialist equipment and use specialist supplies in sterile production preparation

6.6 Perform verification procedures and inspect finished product for deviations and report to authorised person

6.7 Pack compounded product into appropriate container as specified on the work sheet, and following approval from an authorised person

6.8 Label containers according to labelling specifications on the work sheet

6.9 Obtain required authorisation or checks at designated points

7. Complete production process

7.1 Reconcile the number of labels printed with number used and report discrepancies to the pharmacist

7.2 Place product in quarantinearea under appropriate storage conditions

7.3 Clean machinery and manufacturing area and dispose of disposable equipment safely

7.4 Follow procedures for cleaning cytotoxic spills, and exposure to cytotoxic drugs

7.5 Complete required documentation and forward to an authorised person

7.6 Report discrepancies to an authorised person

7.7 Obtain final approval from pharmacist before releasing compounded medicines to storage areas

7.8 Discard waste materials appropriately

8. Participate in quality control

8.1 Pack and label a retention sample and/or quality control sample if specified on the work sheet

8.2 Perform environmental monitoring and report abnormal readings to an authorised person

8.3 Submit product sample and relevant documentation to quality control

8.4 Record and file product quality control assay results and manufacturing area environmental monitoring results

9. Store and transport released product

9.1 Store products according to the work sheet

9.2 Obtain released product(s) from quarantine store

9.3 Pack released product(s) into delivery containers which will maintain the required ambient conditions for the product

9.4 Deliver product to destination ensuring safe transport of cytotoxic products

9.5 Advise receipting area personnel of storage requirements

9.6 Complete and file records and/or work sheets

The candidate must show evidence of the ability to complete tasks outlined in elements and performance criteria of this unit, manage tasks and manage contingencies in the context of the job role. There must be evidence that the candidate has:

followed established procedures and industry codes to accurately and safely produce 10 aseptic products:

worked within the requirements of sterile areas, air locks, laminar flow hoods and cytotoxic drug safety cabinet/isolators

identified issues outside scope of practice and referred these to the authorised person

The candidate must be able to demonstrate essential knowledge required to effectively complete tasks outlined in elements and performance criteria of this unit, manage tasks and manage contingencies in the context of the work role. This includes knowledge of:

legal and ethical requirements (national, state/territory) for pharmacy work, and how these are applied in organisations, including:

codes of conduct

duty of care (and implications of negligence)

privacy, confidentiality and disclosure

records management

rights and responsibilities of workers, employers and clients

specific legislation:

medicines and their use

the practice of pharmacy

different schedules of medicines and pharmaceutical products

work role boundaries – responsibilities and limitations in manufacturing products

work health and safety

key information in standard pharmaceutical references and their use in manufacturing, including:

Australian pharmaceutical formulary and handbook (APF)

MIMs

Australian medicines handbook (AMH)

Micromedex

rationale and key features of:

The Society of Hospital Pharmacists (SHPA) Standards of practice for the safe handling of cytotoxic drugs in pharmacy departments

Pharmaceutical Inspection Convention/Pharmaceutical Inspection Co-operation Scheme (PIC/S) Guide to good practices for the preparation of medicinal products in healthcare establishments (PE010-3)

product identification and handling, including those for:

formulary medicines and non-formulary medicines

products with the required integrity as well as those whose integrity has been compromised

routine of handling products and products requiring special handling

nature and use of different dosage forms, including:

oral

parenteral products

topical

infection control requirements for small scale compounding of aseptic pharmaceutical products, including:

aseptic technique

correct disposal of sharps and residues

cleaning and disinfection processes plus sterilisation of pharmaceuticals

personal hygiene and clothing standards

sources and types of contamination and required responses – microbial, cross-chemical, physical, environmental and corrective strategies

processes relating to aseptic, including:

calculations for all sterile admixtures

chemical and physical properties of materials in relation to formulation and compounding

principles and procedures of formulae calculations, weights and measures

principles of aseptic technique, including cytotoxic manufacturing

processes for dilution, suspension, incorporation and reconstitution

use of terminal filtration

risk considerations and procedures for pharmaceutical manufacturing:

product security

handling and storage of hazardous materials

quarantine periods

management of cytotoxic spills

specific hazards related to cytotoxic manufacture

transport of cytotoxic medications

requirements for formulated manufacturing documentation, including:

different documentation types, their scope and purpose

worksheet processes

information quality requirements (including clarity, logic and completeness)

specific labelling requirements for compounded products, including:

adherence to legislative requirements

name, form and strength of product

ancillary labels as part of label details

hazard warnings

spacing for entry of batch numbers and expiry dates

packaging methods, container materials and principles for selection

storage and transport requirements and rationale for different types of product including:

hazardous materials

special storage considerations:

humidity

isolation

light

temperature

ventilation

features and use of pharmacy systems used for aseptic compounding

circumstances that require compounding of the product within a laminar flow hood/clean room or cytotoxic drug safety cabinet/cytotoxic suite or room or isolator

Skills must have been demonstrated in the workplace or in a simulated environment that reflects workplace conditions. The following conditions must be met for this unit:

use of suitable facilities, equipment and resources, including:

simulated facilities with physically separate areas for preparation/checking of product, hand washing and manipulation of produce

gowns, gloves and hand washing facilities

weighing and measuring equipment

materials (including simulation medicine substitutes such as coloured water) and disposable equipment

note that a clean room environment is not required for simulated assessment

modelling of industry operating conditions, including time constraints for completing activity

Assessors must satisfy the Standards for Registered Training Organisations (RTOs) 2015/AQTF mandatory competency requirements for assessors.

Copy and paste from the following performance criteria to create an observation checklist for each task. When you have finished writing your assessment tool every one of these must have been addressed, preferably several times in a variety of contexts. To ensure this occurs download the assessment matrix for the unit; enter each assessment task as a column header and place check marks against each performance criteria that task addresses.

Observation Checklist

Tasks to be observed according to workplace/college/TAFE policy and procedures, relevant legislation and Codes of Practice Yes No Comments/feedback
 
Select appropriate formula and master work sheet for the product, based on correct interpretation of the prescription or medication order 
Confirm suitability of chosen master work sheet and availability of resources 
Obtain authority of pharmacist to proceed 
Confirm the availability of the appropriate laminar flow hood/clean room or cytotoxic drug safety cabinet/cytotoxic suite or room or isolator required to compound the product according to the work sheet 
Comply with dress code, safety and personal hygiene procedures prior to entering the work area 
Clean work area and equipment correctly 
Maintain inventory levels of materials and disposable equipment 
Prepare a work sheet referenced from amaster work sheet 
Assign product batch number 
Verify that the work sheets are clearly written in logical order with clear directions and contain all the required information 
Generate the product labels referenced from the master label detailed on the master work sheet 
Check and note the number of labels generated 
Submit work sheet and labels to pharmacist for approval 
Check and set up compounding requirements and disposable equipment 
Assemble materials used in aseptic compounding as listed in the work sheet, according to stock levels and stock requisitioning procedures 
Check materials to ensure they have been released from quarantine for use by authorised persons 
Verify materials against manufacturing work sheet and record material batch numbers and expiry dates 
Select appropriate types, size and features of containers and packaging listed in the work sheet 
Weigh or measure materials in designated area 
Obtain required authorisation or checks at designated points according to the work sheet 
Transfer raw materials, disposable equipment, required containers or packaging and covered work sheet to pre-production area 
Follow hand washing, gowning and gloving procedures 
Disinfect and transfer materials, disposable equipment and work sheet to sterile production area 
Check that cytotoxic spill cleaning kits are available in all production areas 
Select and use appropriate sterile personal protective equipment for safe handling and preparation of cytotoxic drugs as required 
Follow specific procedures to minimise risk of exposure to cytotoxic drugs 
Allocate approved bulk materials, intermediary products and containers to appropriate equipment 
Incorporate materials according to work sheet using appropriate manipulation technique 
Compound product according to method on manufacturing work sheet 
Prepare cytotoxic products using procedures for safe handling of cytotoxic drugs 
Operate specialist equipment and use specialist supplies in sterile production preparation 
Perform verification procedures and inspect finished product for deviations and report to authorised person 
Pack compounded product into appropriate container as specified on the work sheet, and following approval from an authorised person 
Label containers according to labelling specifications on the work sheet 
Obtain required authorisation or checks at designated points 
Reconcile the number of labels printed with number used and report discrepancies to the pharmacist 
Place product in quarantinearea under appropriate storage conditions 
Clean machinery and manufacturing area and dispose of disposable equipment safely 
Follow procedures for cleaning cytotoxic spills, and exposure to cytotoxic drugs 
Complete required documentation and forward to an authorised person 
Report discrepancies to an authorised person 
Obtain final approval from pharmacist before releasing compounded medicines to storage areas 
Discard waste materials appropriately 
Pack and label a retention sample and/or quality control sample if specified on the work sheet 
Perform environmental monitoring and report abnormal readings to an authorised person 
Submit product sample and relevant documentation to quality control 
Record and file product quality control assay results and manufacturing area environmental monitoring results 
Store products according to the work sheet 
Obtain released product(s) from quarantine store 
Pack released product(s) into delivery containers which will maintain the required ambient conditions for the product 
Deliver product to destination ensuring safe transport of cytotoxic products 
Advise receipting area personnel of storage requirements 
Complete and file records and/or work sheets 

Forms

Assessment Cover Sheet

HLTPHA007 - Conduct small-scale compounding and labelling of aseptic pharmaceutical products
Assessment task 1: [title]

Student name:

Student ID:

I declare that the assessment tasks submitted for this unit are my own work.

Student signature:

Result: Competent Not yet competent

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Assessor name:

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Assessment Record Sheet

HLTPHA007 - Conduct small-scale compounding and labelling of aseptic pharmaceutical products

Student name:

Student ID:

Assessment task 1: [title] Result: Competent Not yet competent

(add lines for each task)

Feedback to student:

 

 

 

 

 

 

 

 

Overall assessment result: Competent Not yet competent

Assessor name:

Signature:

Date:

Student signature:

Date: