HLTPH407C
Conduct small-scale compounding of pharmaceutical products

This unit of competency describes the skills and knowledge required to manufacture and small scale compounding of non-sterile pharmaceutical products from fixed formulas, including extemporaneous dispensing

Application

All tasks are conducted according to NCCTG Guidelines for the Preparation of Pharmaceuticals in Australian Hospitals and standard operating procedures (SOPs)

Work performed requires a range of well developed skills where discretion and judgement is required

Individuals will take responsibility for their own outputs and limited responsibility for the outputs of others


Prerequisites

Not Applicable


Elements and Performance Criteria

ELEMENT

PERFORMANCE CRITERIA

1. Prepare for production process

1.1 Follow correct dress code, safety and personal hygiene procedures

1.2 Maintain preparation areas at NCCTG Guidelines for the Preparation of Pharmaceuticals in Hospitals requirements

1.3 Clean work area and equipment correctly

1.4 Maintain inventory levels of raw materials and disposable equipment

1.5 Obtain and clarify the confirmed and formulated manufacturing order/master batch sheet from pharmacist

1.6 Prepare production work sheet from formulated manufacturing order/master batch sheet

1.7 Interpret manufacture work sheet and assign appropriate product batch number

1.8 Check and set up manufacturing/compounding machinery

1.9 Prepare production work sheet from master batch sheet / formulated manufacturing order

2. Obtain and process raw materials

2.1 Acquire all materials listed on the worksheet according to stock levels and stock requisitioning procedures

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

2.3 Verify raw materials against manufacturing work sheet and record raw material batch numbers

2.4 Weigh and measure raw materials in designated weighing area

2.5 Allocate raw materials to appropriate manufacturing machinery, where applicable

2.6 Obtain appropriate authorisation/checks at designated points

3. Manufacture/compound products

3.1 Comply with NCCTG Guidelines for the Preparation of Pharmaceuticals in Hospitals and Australian Standards for operator safety when cleaning, setting up work station and transference of all materials

3.2 Allocate approved raw materials to appropriate machinery, where required

3.3 Incorporate raw materials according to batch documentation

3.4 Compound product according to method on work sheet and in compliance with standard operating procedures for any machinery use

3.5 Obtain required authorisation/checks at designated points

3.6 Monitor product and adjust any necessary pharmaceutical/compounding to ensure product complies with work sheet specifications

3.7 Perform checking procedures and inspect finished product for deviations

3.8 Pack product using appropriate packaging devices/machinery as specified on the work sheet, and following approval from an authorised person

3.9 Label containers/units according to labelling specifications on the work sheet

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

4. Complete production process

4.1 Place product in quarantine area under appropriate storage conditions, where specified

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

4.3 Complete machinery and equipment records and/or logs

4.4 Complete documentation and forward to appropriate person

4.5 Complete machinery and equipment records and/or logs

4.6 Reconcile the number of labels printed with number used and discard excess, noting and documenting discrepancies in labels

4.7 Complete documentation and forward to an authorised person

4.8 Report all discrepancies to an authorised person

4.9 Obtain final clearance from an authorised person

5. Participate in quality control

5.1 Submit product sample and relevant documentation to quality control, where specified

5.2 Record and file product quality control assay results

6. Store and transport released product

6.1 Store products according to manufacturing documentation

6.2 Obtain released product(s) from quarantine store

6.3 Pack released product(s) into appropriate delivery containers

6.4 Deliver product to store/dispensary/client care area by appropriate means

6.5 Advise receipting area personnel of any special storage requirements

6.6 Complete and file records and/or work sheets

Required Skills

This describes the essential skills and knowledge and their level required for this unit.

Essential knowledge:

The candidate must be able to demonstrate essential knowledge required to effectively do the task outlined in elements and performance criteria of this unit, manage the task and manage contingencies in the context of the identified work role

This includes knowledge of:

Basic hygiene and the importance of maintaining a clean working environment and equipment

Basic principles of manufacturing processes

Chemical and physical properties of raw materials in relation to formulation and compounding

Compound of a product according to a work sheet

Correct disposal of sharps, drug residues etc

Identification and handling of products, including

formulary drugs and non-formulary drugs eg clinical trial drugs and special access scheme drugs

products with the required integrity as well as those whose integrity has been compromised eg damaged, contaminated or deteriorated stock

routine handling of products and products requiring special handling, eg cytotoxics and its spill management, refrigerated and frozen items, light sensitive materials and flammables

Infection control policies, guidelines and symbols and their relevance to working in a hospital pharmacy

Knowledge of and the rationale for applicable legislation, organisation policy and in-house standard operating procedures (SOPs), relating to small scale compound/manufacture of pharmaceutical products

Labelling requirements for compounded products

Maintenance principles and procedures of clean work environments

Nature and use of different dosage forms

OHS policies, guidelines and symbols and their relevance to working in a hospital pharmacy

Packaging methods, container materials and principles for selection

Personal hygiene and the use of protective clothing

Pharmacy computer systems

Preparation of worksheets

Principles and procedures of formulae calculations, weights and measures

Principles and procedures of maintaining security of pharmaceutical products

Principles of handling and storage of hazardous materials

continued ...

Essential knowledge (contd):

Principles of record keeping and required documentation to be completed

Processes for dilution, suspension, incorporation and reconstitution

Purpose of batch numbering and expiry date on medicines

Purpose of information to be shown on medicine packs, eg product name, batch numbering and expiry date

Sources and types of contamination - microbial, cross-chemical, physical, environmental and corrective strategies

Storage requirements and rationale for different types of product

Essential skills:

It is critical that the candidate demonstrate the ability to:

Complete and file documentation

Compound raw materials correctly and safely to achieve a quality product

Perform quality assurance monitoring

Prepare, process and manufacture quality pharmaceutical products from fixed formulae

Produce a product free from microbial or cross contamination

Refer issues identified outside scope of practice to an authorised person

Transport and store product according to NCCTG Guidelines for the Preparation of Pharmaceuticals in Hospitals

Use personal protective equipment when necessary

Work in a safe manner

Work in accordance with relevant organisation policy, legislative requirements, industrial awards and agreements and in-house operating procedures (SOPs)

continued ...

Essential skills (contd):

In addition, the candidate must be able to effectively do the task outlined in elements and performance criteria of this unit, manage the task and manage contingencies in the context of the identified work role

This includes the ability to:

Assemble, maintain, clean and use all equipment used in manufacturing process in a correct and safe manner and ensure a clean work environments

Calculate drug and non-drug stock requirements for manufacturing

Complete required documentation

Compound a product according to master batch/work sheet

Select and maintain appropriate equipment for manufacturing task

Take into account opportunities to address waste minimisation, environmental responsibility and sustainable practice issues

Use available resources and prioritise workload

Use literacy, numeracy and oral communication skills required to fulfil the position in a safe manner as specified by the health care facility

Use problem solving skills

Evidence Required

The evidence guide provides advice on assessment and must be read in conjunction with the Performance Criteria, Required Skills and Knowledge, the Range Statement and the Assessment Guidelines for this Training Package.

Critical aspects for assessment and evidence required to demonstrate this competency unit:

The individual being assessed must provide evidence of specified essential knowledge as well as skills

Observation of workplace performance is essential for assessment of this unit

Consistency of performance should be demonstrated over the required range of situations relevant to the workplace

Where, for reasons of safety, space, or access to equipment and resources, assessment takes place away from the workplace, the assessment environment should represent workplace conditions as closely as possible

Context of and specific resources for assessment:

Assessment should replicate workplace conditions as far as possible

Simulations may be used to represent workplace conditions as closely as possible
Acceptable simulation requires:

scope to determine that work is conducted within legislative and regulatory requirements

scope to determine that work is conducted within OHS and infection control requirements

Resources essential for assessment include:

access to relevant workplace or appropriately simulated environment where assessment can take place

relevant legislation, regulations and guidelines

weighing and measuring equipment

relevant manufacturing and packing machinery

instructions on the use of equipment

Method of assessment may include:

Observation in the work place (if possible)

Written assignments/projects

Interviewing and questioning

Formal appraisal systems

Supporting statement of supervisor(s)

Access and equity considerations:

All workers in the health industry should be aware of access and equity issues in relation to their own area of work

All workers should develop their ability to work in a culturally diverse environment

In recognition of particular health issues facing Aboriginal and Torres Strait Islander communities, workers should be aware of cultural, historical and current issues impacting on health of Aboriginal and Torres Strait Islander people

Assessors and trainers must take into account relevant access and equity issues, in particular relating to factors impacting on health of Aboriginal and/or Torres Strait Islander clients and communities


Range Statement

The Range Statement relates to the unit of competency as a whole. It allows for different work environments and situations that may affect performance. Add any essential operating conditions that may be present with training and assessment depending on the work situation, needs of the candidate, accessibility of the item, and local industry and regional contexts.

Raw materials may include:

Therapeutic agents

Agents considered inactive, that are required for bulking, stabilising, colouring and flavouring the final product

Batch numbers can include:

Batch numbers can consist of any combination of numerals and digits as specified in standard operating procedures that can uniquely identify an individual product or batch for recording and identification purposes.

Raw materials, manufacturing equipment and packaging devices:

The range of raw materials, manufacturing equipment and packaging devices to be used is specified by the batch/work sheet

Equipment and machinery used in manufacturing may be disposable or non-disposable and may include:

Balances

Meters

Gauges

Measures

Beakers

Mixers

Pumps

Spatulas

Ointment slabs

Filters

Extractors

Stills

Syringes

Needles

Pestle and mortar

Autoclaves

Gloves

Masks

Goggles

Compounding may include:

Trituration

Aggregation

Grinding

Dissolution

Mixing

Emulsification

Suspension

Dose forms may include:

Oral

Topical

Product may include:

Formulary drugs and non-formulary drugs eg clinical trial drugs and special access scheme drugs

Products with the required integrity as well as those whose integrity have been compromised eg damaged, contaminated or deteriorated

Routine handling products and products requiring special handling eg cytotoxics and its spill management, refrigerated and frozen items, light sensitive material and flammables

Product packing may include:

Bulk containers

Client ready units

Containers may include:

Bottles (medical and poison)

Glass jars

Tubes

Syringes

Miscellaneous individual client unit devices

Labels may include:

Typed

Written

Electronically produced

Quarantine period

Quarantine period may be defined as time taken to obtain confirmation of suitability of product/batch for human use.

Storage conditions may include:

Correct temperature

Humidity

Light

Secured

Ventilated

Ambient

Isolated

Correct storage of hazardous substances

Secure and safe storage for controlled drugs

Cleaning methods may include:

Washing

Sweeping

Wiping

Disinfecting

Soaking

De-scaling

Special storage conditions may include:

Refrigeration

Inflammable store


Sectors

Not Applicable


Employability Skills

This unit contains Employability Skills


Licensing Information

Not Applicable