to main content Medication - Sterile Compounding - Using Primary and Secondary Engineering Controls with Testing/Certification Failures | Hospital and Hospital Clinics | Medication Management MM | The Joint Commission
Medication - Sterile Compounding - Using Primary and Secondary Engineering Controls with Testing/Certification Failures

Can we still use our Primary Engineering Control if it fails its testing/certification ?

Any examples are for illustrative purposes only.

It is up to the organization to determine whether or not the compounding space is acceptable to continue producing sterile compounded medication products.  Factors should include the pathogenicity of the organism grown in the positive growth viable sample; complexity level of the compounded product; any known/potential associated hospital acquired infections; and guidance from the infection control practitioner. 
 
Last updated on May 11, 2020
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
Surgeons in an operating room

Additional Resources

Train your staff with a tool to quickly and efficiently assess standards compliance with our 2021 Hospital Compliance Assessment Workbook.

A group of medical professionals have a discussion in a meeting room

Hospital Webinars

Keep learning with our Hospital Breakfast Briefings Webinar Series. Get a deep dive into our standards, chapter-by-chapter, individually or as a team.

Female doctor using digital tablet in her office.

Looking for Standards?

Get key information your hospital needs to achieve and maintain continuous standards compliance and experience operational improvement.