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November 2018

On-Site Sterile Compounding Evaluation

The Joint Commission

On-Site Sterile Compounding Evaluation

The Joint Commission has enhanced its on-site evaluation of sterile medication compounding in hospitals, critical access hospitals, and home care organizations. Hospitals and critical access hospitals can expect additional dialogue during tracer activities, as well as extra surveyor time spent observing compounding processes. To best prepare for these survey enhancements, facilities should focus on environmental assessments (including testing and certification reports for engineering controls) to ensure all required components are tested and within acceptable ranges, product preparation assessment, and appropriate completion of competency assessment for all pharmacy compounding staff.

The Joint Commission


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