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Medication - Sterile Compounding - Compounding Staff Competency Requirements

What competencies are required for personnel compounding medications in the Main Pharmacy or Satellite Pharmacy areas ?

Any examples are for illustrative purposes only.

The following competencies are expected to be completed for all compounding staff:
  • Media fill testing (representing the highest complexity level of compounding performed)
  • Gloved fingertip sampling (initial and ongoing testing)
  • Written didactic testing
  • Evaluation of hand washing and donning PPE
The listed items are expected with the following time frames:
  • Low-Risk and Medium-Risk^ Sterile Compounding:  Annually for staff performing (defined as every 12 months +/- one month.)
  • High-Risk Sterile Compounding*:  Every 6 months
^NOTE: Sterile compounding risk levels are adapted from USP 797
Manual: Hospital and Hospital Clinics
Chapter: Medication Management MM
Last reviewed by Standards Interpretation: May 03, 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 May 03, 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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