Enter the following information as you would like it to appear at the top of your Verification Instruction Sheet:

Institution Name:

Address:

Date:

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MEDIUM-RISK RL-2 KIT VERIFICATION

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STEP 1: Select Transfer Method

Option 1:

Select the method you normally use for transferring bulk solutions when compounding TPNs:
An Automated Compounder
A Transfer Set
A 60 mL Syringe
Other

Option 2:

Select the source and size. If you are using a compounder, select Sterile Water for Injection and the bag or bottle size you normally use. If you select any other method of bulk transfer, you may select Normal Saline or Sterile Water for Injection, and indicate any bag or bottle size which is 50mL or greater.

Select source solution and container:
Sterile Water for Injection
Normal Saline

Enter size of source container mL

Select one:
Bag
Bottle

Option 3: Select Final Container for TPN Simulation

This bag or bottle will be the final container for your simulated TPN. If you use an automated compounder, you must use a compounder bag. If you use both bags and bottles in your practice, select Bag for this option, select Yes for Option 4, and select the bottle in option 6. This allows you to incorporate both types of final container into your verification exercise.

Enter size of final container mL (must be 100mL or larger).

Select one:
Bag
Bottle

Option 4: (Only applicable if a you did NOT select a transfer set in Option 1, and you wish to incorporate the use of a transfer set into your verification.)

Choose Yes If:

• connecting tubing of any kind and/or using transfer sets commonly in your practice, but you are using a compounder
• use a bag in Option 1 and wish to incorporate the use of a bottle, as well

Do you connect a transfer set to the final container and prime?
Yes
No

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STEP 2 through 9: Select Transfer Method

Option 5:

Do you use dispensing pins in your institution?
Yes
No

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STEP 10

Option 6: (Only applicable if you answered Yes to Option 4.)

Choose one:
Transfer 50mL of the media in the bag produced in Steps 1 through 9 into an empty mL Evacuated Container.
Transfer 50mL of the media in the bag produced in Steps 1 through 9 into an empty mL bag.
Do not make a transfer

Option 7:

You may incorporate the use of a repeating syringe by selecting this option.

Do you attach a repeating syringe to the bag/bottle which does not have a transfer set attached and dispense one each 10mL aliquot into each of three empty sterile vials?
Yes
No

Option 8:

Choose this option if you wish to include PCA cassette preparation or increase the complexity of your procedure by including syringe preparation.

From the bag/bottle which does not have a transfer set attached, do you withdraw three each 10mL aliquots?
Yes
No

Option 9: (Only applicable if you answered Yes to Option 8.)

Do you dispense the aliquots prepared in the previous step into three separate PCA cassettes?
Yes
No

Additional Steps:

If there is any other process you want to include in your procedure, you may list it here exactly as you want the instruction to appear. Be aware that the total volume of growth-medium produced in steps 1 through 9 is 100mL and take into account any medium used in any steps after 9 that you have included.

Add additional steps.
Enter each additional statement as it should appear in the instructions.
Separate steps by pressing Enter.

Additional Materials:

If you specified any additional steps above, list any additional tools and materials required, so that they can be added to the Materials List in your procedure.

List materials to be added to materials lists.
Separate material list items by pressing Enter.