Pharmacy Sterile Compounding (USP 797)

USP 797 sterile compounding procedure for low/medium-risk CSPs. Covers garbing, hand hygiene, hood preparation, aseptic technique, and BUD assignment.

Steps

• Verify authorization and compounding order details
• Perform hand hygiene
• Don garb in the required sequence
• Disinfect and prepare the hood or primary engineering control
• Arrange materials to maintain first air
• Perform aseptic compounding manipulations
• Inspect the compounded sterile preparation
• Assign the beyond-use date and document the batch record
• Escalate any deviation or non-conformance
• Release the completed record
• Document the deviation and notify the supervisor