IV PREPARATION EVALUATION SHEET 1

st
2
nd
3 rd

(Circle one)
NAME: __________________BENCH NUMBER: ________________

PREPARATION: _____________________________ _____________________________________

This form is used to evaluate each student's compounding of one of the following sterile preparations:
reconstitution, ampule, or vial. The student is required to evaluate the prescriber's order and then use the most
appropriate procedure and technique to compound the preparation.

An evaluator will observe the student during the compounding of the sterile preparation. The student must follow
the steps listed below during the compounding of the preparation. The evaluator will indicate either "CORRECT"
or "INCORRECT" for each step as the student performs the step. ”INCORRECT” means that either the step was
not performed or was not performed correctly. The evaluator may write additional comments as necessary.
The steps in bold and capital letters are critical. Each critical step has an assigned point value of 30. The
student must perform each critical step to successfully complete the preparation.

The evaluator will total the assigned point value for each step receiving an "incorrect" evaluation. This total will
be deducted from a total possible score of 100 points. A score of 75 or higher is required to pass the preparation.

PART I: PREPARING TO COMPOUND THE STERILE PREPARATION

1. Evaluate the ORDER SHEET and complete appropriate fields on the ADDITIVE PROFILE. Each item is
worth three points unless otherwise indicated.
Demographics and Dose:
DEMOGRAPHICS CORRECT INCORRECT DOSE CORRECT INCORRECT
PATIENT NAME Allergies
Room # Diagnosis
MR# DRUG NAME
Weight (in pounds and kg) Base solution (if provided)
Height (inches and feet & Frequency
inches)
DOB and Age (in years) Administration route
Physician Due time and date

Comments__________________________________________________________________________________
___________________________________________________________________________________________

2. Consult REFERENCES to complete the ADDITIVE PROFILE. Each item is worth three points unless
otherwise indicated.
Sterile Preparation Information:
INFORMATION NEEDED CORRECT INCORRECT
Chose appropriate base solution or container (use references and/or SOPs)
Chose appropriate volume of base solution or container (use references and/or SOPs)
STABILITY TIME OF FINAL PREPARATION IS CORRECT (INCLUDE
REFERENCE)
PER USP <797>, ASSIGNED APPROPRIATE RISK LEVEL, BEYOND-USE
DATE, AND STORAGE CONDITIONS OF PREPARATION

Comments__________________________________________________________________________________
___________________________________________________________________________________________

1
 Indications and Contraindications*:
INFORMATION NEEDED CORRECT INCORRECT
NO DRUG-DRUG INCOMPATIBILITIES
NO DRUG-BASE SOLUTION INCOMPATIBILITIES
DRUG, DOSE, FREQUENCY, & INFUSION RATE ARE CORRECT FOR
PATIENT. INCLUDE REFERENCE. IF REQUIRED, CONTACTED
PHYSICIAN AND DOCUMENTED CALL.
NO CONTRAINDICATED DRUG ALLERGIES.
IF REQUIRED, CONTACTED PHYSICIAN AND DOCUMENTED CALL
NO CONTRAINDICATED MEDICAL CONDITIONS (e.g., renal/hepatic failure)
IF REQUIRED, CONTACTED PHYSICIAN AND DOCUMENTED CALL

* Must contact the MD for clarifications and properly document.

Comments__________________________________________________________________________________
___________________________________________________________________________________________

3. Complete CALCULATIONS on the back side of the ADDITIVE PROFILE. Each item is worth three points
unless otherwise indicated.
CALCULATION CORRECT INCORRECT
Calculated initial concentration of drug in units/mL (from original packaging or if powder
to reconstitute, the concentration you will make)
Calculated final concentration of drug in units per liter (in final packaging /product)
Calculated correct powder and diluents volumes (if reconstitution)
CALCULATED AND RECORDED CORRECT DRUG DOSE AND VOLUME (that
will be given to the patient)
Calculated or selected appropriate rate of administration (milliliters per hour for IV; 15, 30
or 60 minutes for IVPB, minutes or N/A IV Push, IM, SubQ)

Comments__________________________________________________________________________________
___________________________________________________________________________________________

4. Complete all fields on the LABEL using the information gathered. Each item is worth two points unless
otherwise indicated.

LABEL FIELD CORRECT INCORRECT LABEL FIELD CORRECT INCORRECT

PATIENT NAME Route of administration
Room number Due date
DRUG NAME Due time
DOSE (WITH UNITS) Beyond-use date
Base solution (or N/A for Beyond-use time
IV push/syringe)
Volume (base solution or Storage conditions
syringe)
Rate of administration Initials

Comments__________________________________________________________________________________
___________________________________________________________________________________________

2
5. Gather MATERIALS and record on the ADDITIVE PROFILE. Each item worth three points unless otherwise
indicated.
ACTION REQUIRED CORRECT INCORRECT
All materials needed for product manipulation have been gathered prior to entering the hood,
including needles, syringes, drug and diluents
COLLECTED THE CORRECT STERILE PREPARATION COMPONENTS (drugs,
diluents, solutions)
LOT, MANUFACTURER AND EXPIRATION DATE ACCURATELY RECORDED
VIAL TYPE AND BEYOND-USE DATE AND TIME OF ALL VIALS AND
AMPULES ACCURATELY RECORDED
NONE OF THE MATERIALS ARE DAMAGED, CONTAMINATED, OR EXPIRED
Wiped down supplies before leaving main pharmacy work area

Comments__________________________________________________________________________________
___________________________________________________________________________________________

Checked by (TA): Calculation Total Time:

Notes to second TA:

___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________

PART II: MAKING THE STERILE PREPARATION

1. Prepare the HOOD and sterile preparation MATERIALS. Each item is worth two points unless otherwise
indicated.

ACTION REQUIRED CORRECT INCORRECT

Perform garbing technique correctly (hair cover, beard cover (if applicable), face mask, shoe
covers, wash hands, gown, sanitize hands with alcohol, don sterile gloves, and sanitize gloves
with sterile alcohol prior to entering hood

Perform hand-washing technique correctly (provided a verbal description if required)

Donned gloves correctly (provided a verbal description if required)
TURN ON THE HOOD (BLOWER AND LIGHT) AND LET RUN AT LEAST 30
MINUTES BEFORE USE
CLEAN THE HOOD CORRECTLY AND DOCUMENT IT WAS CLEANED
Demonstrates understanding that LAFS must be certified every 6 months, when moved, or if
damaged. Prefilters must be changed monthly (frequency of filter change depends on type of
hood – must check manufacturer’s guide)
CLEAN PRODUCT MATERIALS WITH STERILE ALCOHOL BEFORE PLACING
IN HOOD

Comments__________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________

Checked by (TA): _______________________________

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2. Manipulation Time Starts:
Perform the MANIPULATION (use the correct section below). Each item is worth two points unless
otherwise indicated.

AMPULES CORRECT INCORRECT

REMOVED FLUID FROM NECK OF AMPULE AND SWABBED NECK
OF AMPULE IN PREPARATION FOR NEEDLE ENTRY
Assemble filter needle (or filter straw) and syringe
Enter ampule with proper needle entry technique
Withdraw solution from ampule. Pull volume from needle into syringe before
switching needle.
SWITCH FILTER NEEDLE TO REGULAR NEEDLE (OR FROM
REGULAR NEEDLE TO FILTER NEEDLE) IF INJECTING IN IV BAG.
ACCURATELY MEASURE THE CALCULATED VOLUME OF DRUG
SOLUTION
ADD DRUG SOLUTION TO THE BASE SOLUTION CONTAINER and
seal port

RECONSTITUTIONS CORRECT INCORRECT

OPENED DILUENT VIAL AND SWABBED TOP OF VIAL OR
SWABBED NECK OF AMPULE BEFORE NEEDLE ENTRY
Assemble needle and syringe (if using ampule, filter needle was used)
Enter the diluent vial or ampule with proper needle entry technique
Withdraw diluent from ampule or vial
IF USING AMPULE, SWITCH FILTER NEEDLE TO REGULAR
NEEDLE (OR FROM REGULAR NEEDLE TO FILTER NEEDLE)
ACCURATELY MEASURE THE CORRECT VOLUME OF DILUENT
If use milking technique to reconstitute vial, change needle before adding diluent
to vial to avoid over dilution
Add the diluent to the vial with proper needle entry technique and wait for syringe
equalization before pulling needle and syringe out of vial. Minimizes positive
pressure and avoids aspiration.
Reconstitute the product and check for undissolved drug or particulates
Reswab reconstituted vial and reentered the vial with proper needle entry
technique
ACCURATELY MEASURE THE CALCULATED VOLUME OF DRUG
SOLUTION
ADD DRUG SOLUTION TO THE BASE SOLUTION CONTAINER and
seal port
For partial vials, covered vial stopper with seal before leaving hood.

VIALS CORRECT INCORRECT

OPENED VIAL AND SWABBED TOP OF VIAL BEFORE NEEDLE
ENTRY
Attach needle to syringe
Enter the vial with proper needle entry technique
ACCURATELY MEASURE THE CALCULATED VOLUME OF DRUG
SOLUTION
ADD DRUG SOLUTION TO THE BASE SOLUTION CONTAINER and
seal port
For partial vials, covered vial stopper with seal before leaving hood.

Comments__________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________

4
3. Avoid CONTAMINATION while performing the manipulation. Each item is worth two points unless
otherwise indicated.

ACTION REQUIRED CORRECT INCORRECT

GLOVES WERE SANITIZED PRIOR TO PRODUCT MANIPULATION
GLOVES WERE RESANITIZED THROUGHOUT PROCESS ANY TIME
AN OBJECT OUTSIDE OF THE HOOD WAS TOUCHED.
No object was placed between the HEPA filter and critical areas (i.e. shadowing).
Student may lose up to four points.
NO CRITICAL AREAS WERE TOUCHED OR CONTAMINATED
All work performed 6 inches inside of hood and 6 inches from sides.
Demonstrates proper infection control during compounding. No jewelry visible. No
hair visible outside of hair cover. Ears totally covered by hair cover. Face mask is
covering both nose and mouth. Skin is not visible between gown and gloves.
Keeps nonessential items outside of the hood (including head).

Comments__________________________________________________________________________________
___________________________________________________________________________________________
PART III: DOUBLE-CHECKING & CLEAN-UP
1. Double-check the MATERIALS used, the finished PREPARATION, and the ADDITIVE PROFILE. Each
item is worth two points unless otherwise indicated.

ACTION REQUIRED CORRECT INCORRECT

Shake the bag to disperse the drug and check the integrity of the sterile product
container by squeezing the bag
Check the sterile product for visible particulate matter against a white and black
background
To anteroom for final check: COMPARE ORDER to ADDITIVE PROFILE;
ORDER to LABEL; CHECK BASE SOLN; CHECK LOT, MANU, EXP
DATE of CONTAINERS; check syringes used (do not reuse a syringe; the trash
pile tells story)
REVIEW CALCULATIONS FOR ACCURACY
AFFIX LABEL TO PREPARATION
Affix the label so that no information is obstructed on final container

Comments___________________________________________________________________________________
____________________________________________________________________________________________
Manipulation Time Ends
Checked by (TA): Manipulation Time:

2. Once finished making the product, discard WASTE and label MULTI-USE vials. Each item is worth two
points unless otherwise indicated.

ACTION REQUIRED CORRECT INCORRECT N/A

LABEL SDV AND MDV WITH SOLUTION REMAINING WITH BEYOND-USE
DATE AND TIME AND INITIALS.

LABEL ALL RECONSTITUTED VIALS WITH BEYOND-USE DATE AND

TIME, DILUENT, INITIAL CONCENTRATION, AND INITIALS.

Dispose of sharps (sharps container), vials (vial barrel), ampules and broken glass (glass
box), and trash.

After compounding, degarb in anteroom in reverse order. Dispose of gloves, mask and
beard cover in trash. Gown may be reworn for duration of shift. Gown must be discarded
for hazardous drug preparations. When leave clean side of anteroom, discard hair cover
and shoe covers. Sanitize hands.
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Comments:
____________________________________________________________________________________________
___________________________________________________________________________________________

TIME: 1 point subtracted for each minute > 30.

Calculation time: ______+ Manipulation time: ______ = ______ Points Deducted for Time: ______

PART I: ______ PART II: ______ PART III: ______ TIME: ______ Total Points Deducted: ______

PRELIMINARY GRADE (100 – TOTAL POINTS DEDUCTED). ___________

THE STUDENT SUCCESSFULLY PASSED THE PREPARATION. YES NO

(Circle one)

FIRST ATTEMPT SECOND ATTEMPT THIRD ATTEMPT – ___________

(-0 points mid-term/pre-final) (-0 points mid-term/pre-final) (-10 points mid-term/pre-final)
(-0 points final preparation) (-10 points on final preparation) (-20 points on final preparation)

IF TOTAL TIME LESS THAN 45 MINUTES, ADD 3 POINTS + ___________

POSTED GRADE ___________

General Comments to the Student:

Signature below indicates the following:

1. I have neither participated in nor witnessed any acts of academic dishonesty pertaining to this exam.
2. I will not discuss this product with other students in this lab or other labs.
3. I have been informed of my grade.

_________________
Student Signature Date Evaluator Signature