Sterile compounding is a crucial service that Missouri hospitals provide for its patients. However, it is an activity that involves the risk of error and contamination, so it requires strict adherence to quality standards to ensure patient safety and regulatory compliance.

On June 1, the United States Pharmacopeia released significant revisions to General Chapter <797>, which is the list of sterile compounding standards referenced by the Centers for Medicare & Medicaid Services Conditions of Participation and The Joint Commission. These changes are effective Dec. 1, which may result in significant effort and cost for many Missouri hospitals.

Pharmacy and nursing departments will need to review existing policies and procedures to ensure compliance, and in some cases, significant construction and equipment purchases will be necessary. Documentation, record keeping and training will be affected as well. A thorough understanding of the implications of these changes is required to minimize risk and ensure compliance by the upcoming deadline.

Who does this effect?

• pharmacy
• nursing
• finance
• facilities management
• infection control
• regulatory compliance team