Compounded Sterile Preparation and Medication Safety Pharmacy Program Manager

The Compounded Sterile Preparation (CSP) and Medication Safety Program Manager position is located at VA Puget Sound Health Care System (VAPSHCS). VAPSHCS is a 490 bed, university affiliated teaching, research and clinical center with a diverse Veteran population in outpatient, inpatient, and extended care settings. The Program Manager will work under the Pharmacy Clinical Service Line (PCS), primarily at the Seattle Division.

The CSP and Medication Safety Program Manager is a licensed pharmacist responsible for the development, implementation, management, and reporting outcomes of the CSP and Medication Safety Program. The Program Manager directs, oversees, and supervises activities of all assigned operational, technical and professional personnel, and is the leader for assuring that all USP795, USP797 and USP800 CSP compliance requirements are met in the Sterile Processing and Hazardous Drug Management arenas. Maintenance of all required processes and documentation for completely meeting USP795, USP797, and USP800 are a primary focus of this position. They will develop and implement appropriate procedures, oversees and assures facility compliance with USP795, USP797, and USP800 and other applicable laws, regulations, and standards, ensuring competency of personnel, and assuring environmental control of all compounding areas. CSP Program Management Ensures CSP and hazardous medications are handled and prepared in accordance with all departmental policies/procedures and all State, Federal, and other governing body laws and regulations including VAPSHCS policy, VHA Directives, FDA and DEA regulations, Federal and State Law, NIOSH, USP and TJC standards.

Establishes CSP Committee as required to meet the VHA directive related to compounded sterile preparations. Maintains the CSP and Hazardous Medication program to improve outcomes of patients and to protect healthcare workers. Ensures the facility hazardous medication policy is reviewed yearly, staff are educated on each new hazardous medication introduced into the workplace and is responsible for annual hazardous medication training of all relevant staff. Participates in continuous quality initiatives to assist with the continual improvement of procedures, policies, and overall performance of the program.

Maintains a compounded sterile preparation and hazardous medication quality assurance plan in collaboration with Quality Management and Infection Prevention. Identifies outcome measures to evaluate success of the program and identify opportunities for improvement or expansion. Collaborates with additional services including Facilities Management Service, Industrial Hygiene, Infection Prevention and Environmental Management Services, and provides quarterly reports detailing results of any investigations and corrective actions due to failures in microbial monitoring parameters or engineering controls to the Medical Executive Committee and Pentad through the facility VA CSP Advisory Committee.

Maintains clinical oversight of patients receiving compounded sterile and hazardous medications to ensure safe and effective utilization. Promotes Pharmacy Clinical Services philosophy of multidisciplinary teamwork and customer service and to make patient-focused decisions. Encourages pharmacy activities that support the pharmacy mission using established goals and objectives to make critical decisions.

Collaborates with other pharmacy program managers and supervisors to integrate the Compounded Sterile Preparations and Hazardous Medication Program into the global mission of the department. s. Medication Safety Program Management: Participates as the Pharmacy Clinical (PCS) service line representative for the patient safety committee Reviews and assesses compliance with VHA Handbooks, USP 797 Standards, and EPA regulations and any other accreditation surveys or inspections (e.g.

OIG, TJC, CARF, and OSHA). Develops and implements policies as needed to ensure compliance. Monitors and reviews medication errors.

Reviews data for trends and when systems errors occur, works to correct processes. Actively conducts surveillance of all adverse drug events reported through the VA ADERS reporting program and Adverse Reaction Tracking System. Surveillance may be performed through screening for abnormal lab values, discharge diagnosis, and use of antidotes.

Assists in the quality assurance process for IV infusion smart pumps. Assists in the evaluation process of cabinet based dispensing system (e.g. Omnicell) overrides.

Serves as the pharmacy technical expert on committees and task forces that relate to medication safety (e.g. Root Cause Analysis, Focused Review, and Process Action Team) Work Schedule: Monday through Friday 7:00 am - 3:30 pm Telework: Ad hoc only Virtual: This is not a virtual position. Functional Statement #: 0000000 Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized