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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 and for 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.
Last updated on August 05, 2020
Manual: Hospital and Hospital Clinics
Chapter: Medication Management MM

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