Safety First Blog

Pharmacy at the Helm: Leading USP <800> Compliance Efforts

Posted by Laura Paxton on Aug 31, 2023 10:51:31 AM
Laura Paxton
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For years, the hospital pharmacy has been at the forefront of efforts to meet USP <800> compliance, addressing its myriad physical and cultural requirements. Pharmacy’s central role in USP <800> compliance was one key takeaway from a presentation by Christopher Duphren, PharmD at Augusta University Health at the Georgia USP conference this summer. He outlined a plan for USP <800> compliance to a room full of pharmacists, many of whom are among those still planning and implementing the required safety measures outlined by USP <800>. 

These pharmacists are not alone in their continued efforts towards USP <800> compliance and the immense responsibility placed on their shoulders. Earlier this year, 89% of respondents in a webinar said they would not consider themselves USP <800> compliant. Despite the amount of planning and implementation already complete, many health systems may still be hustling to meet the Nov. 1 deadline. 

Because contamination and exposure can occur at all stages of hazardous drug handling, the pharmacy is ultimately responsible for the health and wellness of ALL healthcare workers who come into contact with the drug itself or even surface contamination. Beyond the pharmacy, these include nurses, physicians, physicians’ assistants, shipping and receiving and environmental services. It’s no surprise then that more than 8 million healthcare workers are exposed to hazardous drugs annually, according to the CDC.

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With USP <800>, the Pharmacy is responsible for protecting all healthcare workers from exposure to hazardous drugs. 

Pause for a moment and consider how many nurses alone work within your organization. Many systems employ thousands of nurses. And then add on physicians, shipping/receiving and environmental services. The numbers are vast and so are the affected areas within your hospital.

Previously, the pharmacy’s hazardous drug exposure concerns were confined to the compounding room and the few pharmacists and personnel who accessed it. Now, the pharmacy is responsible for putting into place the equipment and policies necessary to protect virtually ALL healthcare workers. 

Stressed? 😅 With good reason! 

While other areas of the hospital play a significant role in USP <800> compliance, the ultimate responsibility as far as State Boards of Health and Pharmacy, Centers for Medicare and Medicaid and others are concerned is on the pharmacy’s shoulders. 

The design and construction of the pharmacy cleanroom and the engineering controls is a massive undertaking both in time and budget. However, the piece of USP <800> around the documentation and communication of safe handling and disposal policies can be equally taxing considering, as we stated before, the number of employees and the vast reach.  

How are you managing your Assessments of Risk (AoRs) for hazardous drug lists and implementing the subsequent safe handling and disposal policies? In another survey of webinar attendees we learned that 67% of respondents stored hazardous drug lists and safety information in spreadsheets that were accessible either through their EHR or in their hospital’s intranet. While a spreadsheet may accomplish the USP <800> requirement for documenting making available hazardous drug information, is it the most effective way to actually keep healthcare workers safe from the dangerous effects of hazardous drug exposure?

Alternative options are cloud-based medication safety solutions like Rpharmy’s Rhazdrugs that are easily accessible at the point of care. Rhazdrugs reduces risk of exposure by offering drug safety and disposal protocols in an easy-to-understand and accessible format. Rhazdrugs can be customized to your organization’s workflow and integrates with many solutions already in use at your facility. Also, Rhazdrugs will be populated with your facility-specific policies and protocols as well as links to industry safety references like Safety Data Sheets, FDA, DailyMed, DrugBank. All of this information and more can be easily accessed from your Electronic Health Record whether you use Epic, Cerner, Meditech, or Allscripts. This ensures that critical safety information is in the hands of the healthcare workers who need it, which improves the safety and well-being of all employees AND takes one critical piece of USP <800> compliance off of your plate. 

“Rhazdrugs is great because it’s an easily accessible link in the patient’s Medication Administration Record (MAR) within Cerner. The nurse just clicks on the drug, which tells them it’s hazardous, and then they can click another link that takes them to Rhazdrugs and the safety protocols. It’s all at their fingertips - no searching through papers or calling the pharmacist to get the information they need immediately,” said Berkely Sykes, Pharmacy Operations Manager at Huntsville Hospital and Rpharmy Rhazdrugs user. 

And remember all of those other people who are exposed even though they do not prepare or administer hazardous drugs? Rhazdrugs makes it simple for environmental services also to access protocols for disposal, including spills and cleanup. 

“Rhazdrugs has helped us make drug safety information, including NIOSH guidelines, available to those outside the pharmacy, like nursing and environmental services. Previously it was too much information for the pharmacy to try to pull together and keep updated,” Sykes explained. 

We understand the daily pressure Pharm D’s and other pharmacy leaders are under both in their everyday job duties and now with the additional pressures of USP <800>. Our solutions take some of the stress off by helping your facility comply with USP <800> and ensuring healthcare workers have access to the information they need to protect themselves from dangerous hazardous drug exposure.

Discover the benefits of Rhazdrugs in our 30-second video. Dive deeper into USP <800> with our Safety First Blog, packed with compliance resources. For any medication safety inquiries, don't hesitate to email us at

Topics: Rhazdrugs, Policy, USP <800>, Formweb

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