Medication - Sterile Compounding - Segregated Compounding Area (SCA)

Our hospital has a segregated compounding area in the Emergency Department with an IV hood. Are there any restrictions on what medications can be compounded in that area ?

Organization may utilize a segregated compounding area to prepare items classified as Low Risk Level Compounding as long as the beyond use date does not extend beyond 12 hours. Low Risk items are defined as those items prepared in an ISO 5 environment which:
1. The compounding involves only transfer, measuring, and mixing manipulations using not more than three commercially manufactured packages of sterile products and not more than two entries into any one sterile container or package (e.g., bag, vial) of sterile product or administration container/device to prepare the CSP.

2. Manipulations are limited to aseptically opening ampules, penetrating disinfected stoppers on vials with sterile needles and syringes, and transferring sterile liquids in sterile syringes to sterile administration devices, package containers of other sterile products, and containers for storage and dispensing.

 
Last updated on January 23, 2018
Manual: Hospital and Hospital Clinics
Chapter: Medication Management MM

If no, please comment on how we could improve this response.

If you have additional standards-related questions regarding this topic, please use the Standards Online Submission Form