Medication - Sterile Compounding - Testing/Certification Remediation Requirements for Primary and Secondary Engineering

If our Primary Engineering Control or Secondary Engineering Control certification/testing reports show a value outside of acceptable limits, what should we do ?

Any examples are for illustrative purposes only.

Organizations are required to develop a remediation program to address the identified issue which must include retesting the tested components which were out of range. The remediation process should include an overall review of compliance with procedures including those of compounding staff, cleaning processes and products, and air filtration efficiency.  These should be evaluated to identify any potential adverse impact affecting testing results. 
 
Last updated on May 11, 2020
Manual: Critical Access Hospital
Chapter: Medication Management MM

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