Quality Processes in the Compounding Pharmacy - Infection Preventionist Role

Session Description: The revised United States Pharmacopeia Chapter on Compounding Sterile Preparations < 797> became effective on November 1, 2023. This revision has impacted the Non-Sterile Compounding Preparations Chapter < 795> and other chapters as well. This session is designed to inform the Infection Preventionist about the relevant required elements of performance and provide opportunities for working collaboratively with the Pharmacy Department in achieving compliance with the revised standards and adequately assess ongoing competency of staff for required proficiencies, such as hand hygiene, garbing of personal protective equipment, cleaning and disinfection of environmental surfaces, and particulate and viable air sampling. In particular, the hand hygiene and garbing sequence based upon the sink placement is not detailed in the revised chapter < 797> but left to the individual pharmacy to determine. Recommended process steps will be provided in this session based on possible scenarios encountered at a facility. The Compounding Pharmacy is a specialty niche that greatly benefits from the Infection Preventionist's knowledge and expertise while designing required Standard Operating Procedures that will be instrumental in implementing a robust quality assurance/quality control system for compounded preparations for patients.