Unit of competency Outline

Date retreived
22/07/2026 8:57 PM AWST

Whilst all efforts are made to provide accurate and timely information from the relevant source/documentation, please be aware that the information supplied may not be the most current version. The accuracy of the detail has not been confirmed by the Department and therefore should not be relied upon without first confirming the contents.

Conduct small-scale compounding and labelling of aseptic pharmaceutical products

Conduct small-scale compounding and labelling of aseptic pharmaceutical products

Unit of competency
National Code
HLTPH409A
State Code
WD260
TGA Status
Replaced
DTWD Status
Replaced
Current Release Number
1.00
Current Release Date
07/05/2012
State Implementation and Classification
Approved Date
24/08/2012
Field of Education
060501 - Pharmacy
Original Release Date
24/08/2012
Nominal Hours
50
Description
DescriptorThis unit of competency describes the skills and knowledge required to manufacture and compound sterile pharmaceutical products from fixed formulae. This includes cytotoxic and total parental nutrition (TPN) products
Notes
Elements and Performance Criteria
Source information on formula
  • 1.1 Select appropriate dosage form for product, based on client need and/or against application of medicine
  • 1.2 Use validated resources to source available formulae for required product
  • 1.3 Consolidate and make relevant information available
  • 1.4 Confirm suitability of chosen formula and availability of resources
  • 1.5 Obtain authority of pharmacist to proceed
  • 1.6 Obtain and clarify the confirmed and formulated manufacturing order or master batch sheet from pharmacist, when required
Prepare for production process
  • 2.1 Confirm the need to use the appropriate laminar flow hood/clean room or cytotoxic drug safety cabinet/cytotoxic suite or room or isolator to compound the product
  • 2.2 Clean work area and equipment correctly
  • 2.3 Maintain inventory levels of materials and disposable equipment
  • 2.4 Prepare a batch/work sheet referenced from a master sheet or formulae
  • 2.5 Assign product batch number, if required
  • 2.6 Verify that batch/work sheets are clearly written in logical order with clear directions and contain all the required information
  • 2.7 Generate the product labels referenced from a master label
  • 2.8 Check and note the number of labels generated
  • 2.9 Submit batch/work sheet and labels to pharmacist for approval
  • 2.10 Check and set up compounding machinery or disposable equipment
Obtain equipment, consumables, containers required for manufacturing process
  • 3.1 Acquire all materials used in aseptic production according to stock levels and stock requisitioning procedures
  • 3.2 Check materials to ensure they have been released from quarantine for use by authorised persons
  • 3.3 Verify materials against manufacturing work sheet and record material batch numbers and expiry dates
  • 3.4 Weigh or measure materials in designated area
  • 3.5 Select appropriate types, size and features of containers and packaging in sterile manufacturing
  • 3.6 Obtain required authorisation or checks at designated points
Prepare for sterile manufacturing
  • 4.1 Transfer raw materials, disposable equipment, required containers or packaging and covered work sheet to pre-production area
  • 4.2 Follow hand washing, gowning and gloving procedures
  • 4.3 Disinfect and transfer materials, disposable equipment and work sheet to sterile production area
Prepare for cytotoxic production
  • 5.1 Check that cytotoxic spill cleaning kits are available in all production areas
  • 5.2 Select and use specialist equipment and clothing for the safe handling and preparation of cytotoxic drugs
  • 5.3 Follow specific procedures to minimise risk of exposure to cytotoxic drugs
Compound products using correct aseptic techniques
  • 6.1 Allocate approved bulk materials, intermediary products and containers to appropriate machinery / equipment where required
  • 6.2 Incorporate materials according to batch documentation
  • 6.3 Compound product according to method on manufacturing work sheet
  • 6.4 Prepare cytotoxic products using procedures for handling cytotoxic drugs
  • 6.5 Operate specialist equipment and use specialist supplies in sterile production preparation
  • 6.6 Monitor product and adjust any necessary pharmaceutical/compounding to ensure product complies with work sheet specifications
  • 6.7 Perform verification procedures and inspect finished product for deviations and report to authorised person
  • 6.8 Pack compounded product into appropriate container as specified on the work sheet, and following approval from an authorised person
  • 6.9 Label containers/units according to labelling specifications on the work sheet
  • 6.10 Obtain required authorisation or checks at designated points
Complete production process
  • 7.1 Reconcile the number of labels printed with number used and discard excess, noting and documenting discrepancies in labels
  • 7.2 Place product in quarantinearea under appropriate storage conditions, where specified
  • 7.3 Clean machinery and manufacturing area and dispose of disposable equipment safely
  • 7.4 Follow procedures for cleaning cytotoxic spills, and exposure to cytotoxic drugs
  • 7.5 Complete all required documentation and forward to an authorised person
  • 7.6 Report discrepancies to an authorised person
  • 7.7 Obtain final approval from the pharmacist before releasing packed medicines to storage areas
Participate in quality control
  • 8.1 Pack and label a retention sample and/or quality control sample if specified on the work sheet
  • 8.2 Perform environmental monitoring and report abnormal readings to an authorised person
  • 8.3 Submit product sample and relevant documentation to quality control, where specified
  • 8.4 Record and file product quality control assay results and manufacturing area environmental monitoring results
Transport and store release product
  • 9.1 Store products according to manufacturing documentation
  • 9.2 Obtain released product(s) from quarantine store
  • 9.3 Pack released product(s) into delivery containers which will maintain the required ambient conditions for the product
  • 9.4 Deliver product to destination ensuring safe transport of cytotoxic products
  • 9.5 Advise receipting area personnel of storage requirements
  • 9.6 Complete and file records and/or work sheets
RANGE STATEMENT

The Range Statement relates to the unit of competency as a whole. It allows for different work environments and situations that may affect performance. Add any essential operating conditions that may be present with training and assessment depending on the work situation, needs of the candidate, accessibility of the item, and local industry and regional contexts.


Information may include:
Equipment required
Packaging and label requirements
Preparation instructions
Raw drug materials list
Storage and stability data


Master sheet or formulae must:
Be clearly written
Be in logical order
Contain all required information
Contain no ambiguous directions


All materials used in manufacturing may be disposable or non-disposable and may include:
Automated compounding machines
Balances
Closing caps
Filters
Gauges
Meters
Mini spikes
Needles
Ointment slabs
Pumps
Spatulas
Syringes
Syringe connectors
Three way taps


Compound product may include:
Aggregation
Aseptic admixture
Aseptic transfer of materials from one vessel to another
Dilution
Dissolution
Mixing
Trituration


Pack product may include:
Bulk containers
Client ready units


Containers may include:
Eye droppers
Miscellaneous individual client unit devices
Small and large volume infusions bags
Syringes
Vials


Labels may be:
Electronically produced
Typed
Written


Storage conditions may include:
Ambient
Correct storage of hazardous substances
Correct temperature
Humidity
Isolated
Light
Secure and safe storage for controlled drugs
Secured
Ventilated


All required documentation may include:
Machinery and equipment logs
Machinery and equipment records


Destination may include:
Client care area
Dispensary
Store
EVIDENCE GUIDE

The evidence guide provides advice on assessment and must be read in conjunction with the Performance Criteria, Required Skills and Knowledge, the Range Statement and the Assessment Guidelines for this Training Package.

Critical aspects for assessment and evidence required to demonstrate this competency unit:
The individual being assessed must provide evidence of specified essential knowledge as well as skills
Observation of workplace performance is desirable for assessment of this unit
Consistency of performance should be demonstrated over the required range of situations relevant to the workplace
Where, for reasons of safety, space, or access to equipment and resources, assessment takes place away from the workplace, the assessment environment should represent workplace conditions as closely as possible


Context of and specific resources for assessment:
Simulations may be used to represent workplace conditions Acceptable simulation requires:
Scope to determine that work is conducted within legislative and regulatory requirements
Scope to determine that work is conducted within WHS and infection control requirements
Resources essential for assessment include:
Equipment that demonstrates an understanding of aseptic/cytotoxic production processes
Instructions on the use of equipment
Relevant legislation, regulations and guidelines
Relevant manufacturing and packing machinery
Weighing and measuring equipment
Note that assessment for this competency unit does not replace initial and ongoing formal validation processes required in the workplace to undertake aseptic or cytotoxic production (This usually requires the preparation and microbiological sampling of a number of prepared products for initial validation and at regular future intervals, as part of ongoing validation)


Method of assessment may include:
Formal appraisal systems
Interviewing and questioning
Observation in the work place (if possible) or simulated laminar flow hood/clean room or cytotoxic drug safety cabinet/cytotoxic suite or room
Supporting statement of supervisor(s)
Written assignments/projects, e.g. for fundamentals of microbiology and principles of cleaning and disinfection
Formal validation processes required in the workplace to undertake aseptic or cytotoxic production are outside the assessment for this competency unit.


Access and equity considerations:
All workers in the health industry should be aware of access and equity issues in relation to their own area of work
All workers should develop their ability to work in a culturally diverse environment
In recognition of particular health issues facing Aboriginal and Torres Strait Islander communities, workers should be aware of cultural, historical and current issues impacting on health of Aboriginal and Torres Strait Islander people
Assessors and trainers must take into account relevant access and equity issues, in particular relating to factors impacting on health of Aboriginal and/or Torres Strait Islander clients and communities
Replaces
State Code National Code Title Type
D8425 HLTPH415B Conduct small-scale compounding of aseptic pharmaceutical products Unit of competency
Replaced By
State Code National Code Title Type
AUZ91 HLTPHA007 Conduct small-scale compounding and labelling of aseptic pharmaceutical products Unit of competency