Medication - Sterile Compounding - Primary Engineering Control (PEC) Testing/Certification Requirements

What testing is required for our Primary Engineering Controls (Laminar Air Flow Work Bench; Compounding Aseptic Isolator, Biological Safety Cabinets, etc.) ?

The following items are expected to be tested at a minimum with a frequency not to exceed 6 month intervals.  Lack of testing of these items will result in non-compliance with Joint Commission standards. 
• ISO level of the primary engineering control
• Viable particle testing surface of the primary engineering control
• Viable particle testing air within the primary engineering control
• HEPA filter leak test of the primary engineering control
• Evidence of remediation/retesting if assessed levels were not in compliance with those listed in USP 797
 
Last updated on January 23, 2018
Manual: Home Care
Chapter: Medication Management MM

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