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 listed items are expected with the following time frames:
^ NOTE: Sterile compounding risk levels are adapted from USP 797
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
• 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
Last updated on October 27, 2021
Manual:
Critical Access Hospital
Chapter:
Human Resources HR
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