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Record W2013079805 · doi:10.4212/cjhp.v66i3.1250

Lessons Learned from Compounding Tragedies

2013· article· en· W2013079805 on OpenAlexvenueaboutno aff
Eric S Kastango

Bibliographic record

VenueThe Canadian Journal of Hospital Pharmacy · 2013
Typearticle
Languageen
FieldHealth Professions
TopicSafe Handling of Antineoplastic Drugs
Canadian institutionsnot available
Fundersnot available
KeywordsCompoundingMedicinePharmacyFamily medicinePharmacology

Abstract

fetched live from OpenAlex

Several months have passed since news broke of a horrific compounding tragedy at the New England Compounding Center (NECC) in Framingham, Massachusetts. An outbreak of fungal meningitis in fall 2012 was traced to contaminated methylprednisolone acetate prepared by the NECC. According to the US Centers for Disease Control and Prevention (CDC), as of May 11, 2013, 55 deaths and a total case count of 741 had been attributed to the contamination, and the numbers continue to rise. Patients who received medications from this pharmacy have also experienced paraspinal, spinal, and peripheral joint infections. The Institute for Safe Medication Practices (ISMP) has compiled a list of selected compounding misadventures since the 1990s. For legal reasons, many compounding misadventures never become public, but the US Food and Drug Administration (FDA) has been actively inspecting compounding pharmacies with a history or suspicion of large-scale compounding or quality concerns. Compounding problems are not isolated to the United States. Recently, more than 1200 cancer patients in Ontario and New Brunswick received chemotherapy solutions with concentrations below labelled specifications. It appears that jurisdictional issues regarding proper oversight of this operation and others were similar to the problems identified in relation to the NECC event. It is time to face our naivete and our occasional arrogance about safe compounding practices. We must learn from these events and take measures to ensure that we are doing everything possible to protect patients and reduce the risk of improperly compounded sterile preparations. On a personal level, I have been profoundly affected by the NECC event, and I continue to be perplexed by the actions of some of my colleagues who somehow still believe that the principles of contamination control and robust quality systems don’t apply to them. As a pharmacist and a potential future patient, I ask, “What are you doing for your present-day and future patients in light of these recent issues?” Whether you agree or disagree with United States Pharmacopeia (USP) Chapter and other USP chapters critical to compounding or the Pharmaceutical Inspection Cooperation Scheme’s compounding guide, the message couldn’t be clearer. Business as usual is no longer acceptable. We must embrace standards and guidelines that incorporate evidencebased science and best practices that have been vetted through public comment and review cycles. More specifically, it is time to perform risk assessments of the compounding methods used in our own pharmacies, so that inherent risks can be identified and mitigated through detailed policies and procedures, robust training programs and quality systems. Pharmacy staff members must know not only what is expected of them as they prepare sterile dosage forms, but also why they are expected to do these things. We must move away from the pure apprenticeship model of training and instead deploy methods and procedures that establish a solid foundation for quality work practices that will prevent compounding errors. Pharmacy practitioners are increasingly challenged to prepare compounded sterile dosage forms that are not commercially available, at times using nonsterile active pharmaceutical ingredients. Handling and transforming these components into appropriate sterile dosage forms may require greater experience and expertise than a particular pharmacy possesses. In such cases, we must take these limitations into account and recognize the risks they pose to our patients. In particular, only robust and validated procedures should be used. We have the responsibility to ensure that any compounded preparation is what it is expected to be and, to the degree possible, to ensure and measure its sterility. Conversely, if we don’t have the requisite expertise, we should not undertake these activities. Historically, pharmacists compounded medications in a “just in time” manner. However, current distribution models require that more compounded sterile preparations be stored at room temperature, prompting the desire for longer beyond-use dating. The sterility tests described in USP Chapter

Fetched live from OpenAlex and de-inverted. Abstracts are not stored in this database: the inverted indexes are 8.6 GB of the frame’s 9.3 GB of text, and the host has 13 GB free.

How this classification was reachedexpand

Full frame distilled prediction

Teacher imitation

Not calibrated prevalence, not ground truth. Human validation pending. Learned from the 10,348 direct Codex labels and 10,348 direct Gemma labels. Candidate is the union of thresholded teacher heads; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels or direct frontier model labels.

metaresearch head score (Codex)0.001
metaresearch head score (Gemma)0.001
Version: codex-gemma-dda1882f352aValidation status: machine_predicted_unvalidated
Candidate categoriesScience and technology studies, Insufficient payload (model declined to judge)
Consensus categoriesInsufficient payload (model declined to judge)
DomainCandidate signal: none · Consensus signal: none
Study designCandidate signal: Not applicable · Consensus signal: Not applicable
GenreCandidate signal: Empirical · Consensus signal: Empirical
Teacher disagreement score0.136
Threshold uncertainty score1.000

Codex and Gemma teacher scores by category

CategoryCodexGemma
Metaresearch0.0010.001
Meta-epidemiology (narrow)0.0000.000
Meta-epidemiology (broad)0.0000.000
Bibliometrics0.0000.000
Science and technology studies0.0010.000
Scholarly communication0.0000.000
Open science0.0010.000
Research integrity0.0000.001
Insufficient payload (model declined to judge)0.0030.001

Machine scores (provisional)

The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.

Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.

Opus teacher head0.138
GPT teacher head0.413
Teacher spread0.275 · how far apart the two teachers sit on this one work
Validation statusscore_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from it

Classification

machine, unvalidated

Machine predicted; both teacher heads agree on what is shown here.

Study designNot applicable
Domainnot available
GenreEmpirical

How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".

Quick stats

Citations5
Published2013
Admission routes2
Has abstractyes

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