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Loomis et al
Table 1. Summary of Refresher Training Interventions.
Topic

Required for

Calculations All sterile
compounding
personnel (n = 262)
Beyond-use All sterile
dating
compounding
personnel (n = 246)
Refresher
Sterile compounding
training
personnel who
course
compound in a CAI
(n = 199)

Refresher
training
course

Sterile compounding
personnel who
compound in laminar
flow hoods
(n = 90)

Method

Content

Duration

Online

Ratios/proportions, dosage calculations, dilution, concentration and
percentage strength, displacement volume, flow rates, and alligations

1 hour

Online

Risk levels, expiration date, beyond-use date, stability, immediate-use
products

30 minutes

Online

General:
1.25 hours
Introduction to parenteral preparations, influences of contamination,
compounding environment and engineering controls, compounding
equipment, garbing and gloving, aseptic technique, and quality assurance
CAI specific:
Parts of the CAI (gloves, sleeves, airlock chamber, inner chamber,
pressure gauge), filtration, cleaning, and disinfecting
In-person General:
4-6 hours
Introduction to parenteral preparations, influences of contamination,
compounding environment and engineering controls, compounding
equipment, garbing and gloving, aseptic technique, and quality assurance
Activities:
Sterile compounding practice questions and example calculations, product
manipulation with demo vials and ampules, aseptic technique validation
HD specific:
Introduction to USP Chapter 800, exposure risk, engineering controls
and compounding environment, garbing and gloving, and storage

Note. CAI = compounding aseptic isolator; HD = hazardous drug; USP = United States Pharmacopeia.

written, sterile compounding knowledge-based exam; (2)
media-fill challenge test; and (3) an observation assessment
of aseptic technique utilizing an aseptic technique rubric
(done in conjunction with the media-fill challenge test). The
written assessment comprised of 30 questions related to 5
topics: sterile compounding calculations (n = 5), compounding equipment and supplies (n = 6), facilities (n = 9), aseptic
technique (n = 7), and assignment of BUD (n = 3). The mediafill challenge test procedure was developed to create complexity and repetition, ultimately requiring the compounder to
complete a series of 14 steps. As AHC also utilizes closed
system transfer devices in HD sterile compounding, a HD
media-fill challenge test was also required for HD personnel.
Personnel responsible for both HD and non-HD sterile compounding completed both types of media-fill challenge tests.
Observation of aseptic technique was completed by a superuser utilizing an aseptic technique rubric. The aseptic technique rubric was completed during each media-fill challenge
test and consisted of 14 different competency criteria marked
as pass, fail, or not applicable. The aseptic technique rubric is
available in Supplemental Appendix A and the written exam
is available in Supplemental Appendix B.

Refresher Training Intervention
Following completion of the preintervention assessments, current sterile compounding personnel participated in the
refresher training intervention, which was completed
November 2016 through February 2017. The purpose of

refresher training was to review pertinent sterile compounding
information and proper aseptic technique to standardize sterile
compounding knowledge and expertise across the health system. Refresher training required completion of a 1-hour online
review of sterile compounding-related calculations, a 30-minute online review of BUD assignment, and a 1-day, in-person
refresher training course which included hands-on review of
aseptic technique and major knowledge-based concepts within
USP Chapter 797. For personnel practicing at sites with a
compounding aseptic isolator (CAI), there was an alternative
75-minute online refresher training course in place of the inperson training course. Personnel responsible for HD sterile
compounding reviewed additional material specific to USP
Chapter 800 content. All online training modules were developed for and completed through AHC's electronic teaching
platform software. The activities and requirements of refresher
training interventions are summarized in Table 1.

Postintervention
From March through June 2017, after completion of refresher
training interventions, postintervention assessments were completed. Postintervention assessments consisted of the same 3
assessments conducted during the preintervention phase including (1) written, knowledge-based exam; (2) media-fill challenge
test; and (3) an observed assessment of aseptic technique.
Results from preintervention and postintervention assessments were collected and scored. The 30-question, written
exam was graded with a total score of 30 and final scores
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