Pharmacy Practice NewsJoint Commission’s Most Cited Sterile Compounding Deficiencies

Hospital pharmacies struggle with immediate-use compounding oversight as Joint Commission surveys reveal unclear ownership between pharmacy and nursing departments creates the most common compliance failures. Survey data shows 58% implemented training, but 34% uncertain or incomplete on immediate-use protocols affecting patient safety across operating rooms and clinical areas.

⚖️ PROFESSIONAL IMPACT

• Pharmacy departments lack authority over non-pharmacy staff performing immediate-use compounding, creating competency validation gaps in nursing, anesthesia, and clinical departments performing sterile procedures.
• Cleanroom environment deterioration goes undetected as IV workflow software reduces physical inspections—managers discover wall damage, contamination risks, and storage violations only during surveys.
• Environmental services turnover creates recurring training burden with outsourced cleaning staff requiring explicit surface-by-surface protocols and supervised competency validation for each new worker.
• Non-pharmacy visitor access threatens sterile environment when maintenance, plumbing, and student groups enter cleanrooms without standardized garbing competency or continuous supervision protocols.

🎯 ACTION ITEMS

• Establish pharmacy-led immediate-use compounding committee including nursing, anesthesia representatives to create unified SOPs.
• Implement monthly cleanroom walk-throughs rotating compliance technician, infection prevention, and facilities supervisor for multi-perspective assessment.
• Develop visitor competency quiz requiring SOP review, signed compliance agreement, and continuous supervision for all non-pharmacy cleanroom access.
• Document viable sampling action plans with problem description, resolution steps, end status, and closure evidence for survey readiness.

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