Supervisor, Sterile Compounding (FT-Edison)

Overview

Our team members are the heart of what makes us better. At Hackensack Meridian Health we help our patients live better, healthier lives — and we help one another to succeed. With a culture rooted in connection and collaboration, our employees are team members. Here, competitive benefits are just the beginning. It’s also about how we support one another and how we show up for our community. Together, we keep getting better - advancing our mission to transform healthcare and serve as a leader of positive change.

The IV Supervisor is responsible for the education, training, supervising and enforcement of current USP 797 standards and upcoming USP 800 standards. Perform daily coordination tasks of the preparation and distribution of sterile products including intravenous admixtures, irrigation and parenteral nutrition solutions, chemotherapy and miscellaneous products. 

Also responsible for coordination of work assignments and overall supervision of pharmacists and technicians. Validate pharmacist and technician staff competency in sterile technique and adherence to best practices as outlined in USP 797.  Manage IV workflow, validates TPN orders and prescribed chemotherapy regimens. Accurately prepare and dispense medications, maintain records documenting all transactions and significant interventions. Utilize pharmacy computer systems for charges and credits for patient accounts. Provide oversight for inventory management.

Responsibilities

A day in the life of a Supervisor, Sterile Compounding at Hackensack Meridian Health includes:

1. Responsible for the enforcement of current and future USP 797/USP 800 processes and procedures for clean room operation, sterile products compounding and hazardous drug handling and storage. Train, supervise, and educate all pharmacy personnel on proper USP 797 and USP 800 processes and procedures.

Assess competency of all staff working in the IV areas. Responsible for meeting all quality standards and QA audits on clean room and personnel as required for CSPs, including but not limited to; media fill testing, fingertip testing, surface testing, clean room certification, hood certification, particle counts and air quality certification. 

Perform monthly IV room checks to ensure that medications are properly and safely stored, that excess and outdated drugs are removed, and that information regarding drug usage and administration is communicated to pharmacy and nursing staffs. 

Manage daily coordination of the manufacturing and distribution of sterile products, including intravenous admixtures, irrigating solutions, total parenteral nutrition solutions, chemotherapy products and miscellaneous products. 

Oversee coordination of all shifts which include supervising pharmacists and technicians, assigning work and delegating tasks and responsibilities, and for handling problems that arise during the absence or unavailability of the pharmacy supervisors. Maintain policies and procedures of the IV room: gowning, logs, cleaning, and environment.

2. Manage IV workflow while managing technicians appropriately. Ensure accurate and timely completion of batches. Prepare, label, and dispense parenteral drug products using appropriate aseptic technique. Verify accuracy of TPN orders and enters TPN information in a timely fashion. Contact physicians on any questionable IV/TPN orders. Familiarity with normal concentrations of additives in the geriatric, adult, adolescent, pediatric and neonatal populations. Capable of calculating fluid, electrolyte and caloric needs. Successfully completes all mandatory competencies by assigned date.

3. Accurately prepare and dispense (and/or directly supervises) drug products throughout the hospital in a timely fashion. Ensure appropriateness of drug, dose, route, frequency, and duration for each medication ordered before dispensing.

Automatically substitute medications following the Automatic Substitution Policy. Clarify clinical ambiguities with the prescriber and complete order clarification appropriately. Correct profiled orders when errors noted or if there is potential for misinterpretation. 

Ensure accuracy of all work completed by support staff (including accuracy of cassette filling when applicable).  Prioritize individual workflow and shift/expand assignments when requested. Utilize intervention documentation application. 

Adhere to non-formulary decision tree tool. Adhere to approved process of identifying and reporting of medication errors. Maintain accurate records as required by policy and procedure to document drug transactions with the Pharmacy and throughout the hospital. Review patient profiles to ensure appropriate and safe drug therapy. No therapeutic duplication. Prevent significant drug interactions and avoidable adverse drug events secondary to allergies. 

Ensure medications ordered are appropriate for patient height, weight, age, renal function and disease state for the geriatric, adult, adolescent, pediatric, and neonatal populations. Clarify questionable and/or controversial orders with the physician. Serve as a resource for drug information and utilizes appropriate reference materials. Communicate outstanding issues with covering pharmacists. Competent in vancomycin dosing protocol. Successfully complete all mandatory clinical competencies by assigned date. Understand and access physician portal when necessary.

4. Obtain necessary medications when out of stock or inventory is below par. Inform management of inventory issues, or unusual usage of a medication. Loan and Borrow medications as per procedure. Ensure IV/chemo (including assigned refrigerator inventories) unit inspections are completed accurately and by assigned date. Communicate issues with inspections with pharmacy management.

5. Utilize the pharmacy computer system to fulfill job requirements. Appropriately charge and credit patient accounts. Accurately minimize order entry errors (<0.5%). Average a minimum order entry rate of 20 orders/hour. Document all significant interventions accurately and average a minimum of 20 interventions. Adhere to appropriate procedures and notify ISD and Pharmacy Management of outstanding hardware/software issues. Strong working knowledge of the ADC system. Strong working knowledge of the Narc Vault application.

6. Other duties and/or projects as assigned.

7. Adheres to HMH Organizational competencies and standards of behavior.

Qualifications

Education, Knowledge, Skills and Abilities Required:

1. Graduate of an accredited College of Pharmacy; Minimum BS in Pharmacy
2. Minimum 3 years of hospital/IV compounding experience as a registered pharmacist; management experience required; Well-versed in USP 797 and USP 800
3. General pharmacy knowledge, excellent written and verbal communication skills, computer literate

Licenses and Certifications Required:  Registered Pharmacist License.