Medication - Sterile Compounding - Compounding Staff Competency Requirements
What competencies are required for personnel compounding medications in the Main Pharmacy or Satellite Pharmacy areas ?
Any examples are for illustrative purposes only.
The following competencies are expected to be completed for all compounding staff:
The following competencies are expected to be completed for all compounding staff:
- Media fill testing (representing the highest complexity level of compounding performed)
- Gloved fingertip sampling (initial and ongoing testing)
- Written didactic testing
- Evaluation of hand washing and donning PPE
The listed items are expected with the following time frames:
- Low-Risk and Medium-Risk^ Sterile Compounding: Annually for staff performing (defined as every 12 months +/- one month.)
- High-Risk Sterile Compounding*: Every 6 months
^NOTE: Sterile compounding risk levels are adapted from USP 797
Manual:
Critical Access Hospital
Chapter:
Medication Management MM
Last reviewed by Standards Interpretation: May 03, 2022
Represents the most recent date that the FAQ was reviewed (e.g. annual review).
First published date: January 23, 2018
This Standards FAQ was first published on this date.
This page was last updated on May 03, 2022
with update notes of: Review only, FAQ is current
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