Methodist Mansfield Medical Center stepped out ahead of the pack, becoming the first hospital in Texas to set up a new federally-mandated area to prepare hazardous drugs.
Pharmacists can safely mix cancer drugs and other carcinogens in the new USP 800 room, named after the United States Pharmacopeia chapter 800 that mandated it, explained Velvette Davis, the hospital’s director of pharmacy. Other drugs that might be prepared in the USP 800 room include blood thinners, high blood pressure medications, estrogen, testosterone and medications to battle blood disorders, Davis said.
The new regulations mandated that healthcare institutions that mix hazardous drugs have the new rooms in place by February, then extended the deadline to July 2018 because of the construction needed. But Methodist Mansfield opened its USP 800 room in June 2015.
The new pharmacy quarters are part of Methodist Mansfield’s $118 million, 208,000-square-foot expansion, that also added 86 new beds and the Amon G. Carter Foundation Heart & Vascular Center, said Angel Biasatti, the hospital’s director of marketing and community relations.
“Since we were already in construction, we saw this as an opportunity to add this room with construction,” Davis said. “We wanted to get ahead of the game.”
The hospital, which already had a room to prepare chemotherapy drugs and a USP 797 clean room, built new and larger facilities for both of those rooms, too, Davis said.
The hospital prepares approximately 400,000 doses per quarter, Davis said, which can range from vitamins and antibiotics to morphine and cancer drugs. The rooms protect the rest of the hospital and the pharmacists mixing the strong drugs.
“Estrogen is a hormone that can cause a reaction whenever that medication is manipulated and can get in through skin penetration,” Davis explained. “A male employee can get low does in his blood stream just from handling it.”
Other drugs are airborne.
“The air handler for the USP 800 room is massive,” Davis said. “It’s larger than the air handler for the entire hospital to protect the internal environment in the pharmacy and also protects the environment around the hospital.”
Methodist Mansfield’s USP 800 room was the first certified by Titan Tech, a North Richland Hills company that certifies clean rooms, Davis said.
“There are still only a few in Texas,” she said. “The Texas State Board visited and they were very impressed. Of the 500 facilities they review, we were the first.”
Being the first took some creativity, Davis admitted.
“We reviewed the chapter and looked at compliance,” she said. “The chapter changed four times. Even after we had been using the room, there were still revisions until December. We went with the most strict compliance standards.”
The hospital puts safety first, said Methodist Mansfield President John Phillips.
“Methodist Mansfield is always looking for ways to further the safety and quality of our healthcare,” Methodist Mansfield Medical Center President John Phillips says. “The USP 800 room is just one way we are protecting our employees and providing our pharmacists a safe place to customize medications to meet the individual needs of our patients.”