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 and for items with limited stability once compounded.  Therefore, The Joint Commission will not evaluate staff performing this type of compounding with an expectation that they have Finger Tip and Media Fill testing completed as a component of their competencies.
Last updated on May 11, 2020
Manual: Home Care
Chapter: Medication Compounding MC

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