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Medication - Sterile Compounding - Nurse Competency Requirements

Are we required to do Finger Tip Testing and Media Fill Testing on nurses who compound emergent-use items outside of the pharmacy ?

Any examples are for illustrative purposes only.

No, immediate-use compounding is reserved for situations where an immediate/urgent need for medications is present and a delay in waiting for the pharmacy to compound items could delay care, as well as items with limited stability, once compounded.  Therefore, The Joint Commission will not require fingertip or media fill competencies for nurses  performing  immediate-use compounding outside of the pharmacy.
Manual: Home Care
Chapter: Human Resources HR
Last reviewed by Standards Interpretation: April 19, 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 April 19, 2022 with update notes of: Review only, FAQ is current Types of changes and an explanation of change type: Editorial changes only: Format changes only. No changes to content. | Review only, FAQ is current: Periodic review completed, no changes to content. | Reflects new or updated requirements: Changes represent new or revised requirements.
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