Is it an infection control violation for the pharmacy to store cardboard boxes in a room designated for bulk storage?

Ask The Expert, February 21, 2007

I presume from your description that the "bulk storage" room is physically separate from the rest of the pharmacy and staff store stuff in the cardboard boxes until such time as the item is needed, at which point they empty and discard the box.

If staff are also holding on to discarded cardboard in that space, I would look at that as a practice that increases the infection control risk based on the characteristics of an intact box versus a box that isn't intact.

If a question about this came up during survey, the only defense you would be able to mount is if you had conducted a risk assessment of that practice from an infection control perspective. I would assemble a small group, including your infection control practitioner, to look over the process and make a final determination.

If you need a sample format, I've found the one developed by the University of Leeds to be pretty useful with groups of varying familiarity with the risk assessment process.

You may also need to determine the risk of this practice as a function of USP 797, Pharmaceutical Compounding-Sterile Preparations, and whether the storage room has appropriate separation from high-risk pharmacy activities.
The final concern is the size of the storage room. If the room is less than 50 sq. ft. in area, you have less to worry about from a fire protection standpoint, though there is some risk due to the amount of combustible materials stored therein.

If the space that is larger than 50 sq. ft. but  less than 100 square feet, you need to make sure the door to the room has an automatic closer (no door wedges) and the room has automatic sprinklers and smoke barrier protection.

If you go over 100 sq. ft., then you must observe the same provisions as above, but instead of smoke barrier protection, you need to ensure that the room is enclosed with a one-hour fire barrier. Your facilities folks should be able to walk you through this aspect.

That said, regardless of room size, I think providing automatic sprinkler coverage is the way to go for such a storage space.

Ask the Expert features advice from Steven MacArthur, a safety consultant with The Greeley Company in Marblehead, MA. If you have additional questions or require further information, please feel free to contact him at smacarthur@greeley.com.