Joint Commission urges providers to prevent medication compounding-related errors

Accreditation Insider, April 11, 2017

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In a recent blog post, The Joint Commission called on providers to work toward the elimination of medication compounding-related infections (MCRI). When not mixed in sterile conditions, compounded medicines can cause several types of infections, including bacterial bloodstream infections and cases of fungal meningitis.

MCRIs were in the news recently, after a three-month trial wrapped up last month in which the president of a Boston compounding pharmacy was convicted of racketeering and mail fraud stemming from a 2012 fungal meningitis outbreak that infected 778 and killed 76.

“The health care community, including The Joint Commission, recognize that as the need for compounded medications continues to grow it is more important than ever to ensure safe policies and procedures are being appropriately and effectively implemented to prevent patient harm,” wrote Robert Campbell, PharmD.

In the post, Campbell reminds providers that guidelines for compounding medications (sterile and non-sterile) are derived from the United States Pharmacopeial Convention’s (USP) General Chapters <797>, <795>, and <800>. USP Chapter <800> goes into effect in 2018 and covers guidelines for compounding hazardous materials.  All three chapters have requirements on the environment, personnel, and products used during compounding.

Campbell writes that many facilities still struggle with compounding compliance. In response, The Joint Commission unveiled a new Medication Compounding Certification (MCC) program in January. All compounding pharmacies are eligible to enroll in the program including organizations not accredited by The Joint Commission. The accreditor says that the goal of the MCC program is to:

•    Ensure pharmacies are compliant with USP and Joint Commission standards
•    Reduce the risk and harm stemming from drug compounding
•    Uncover and fix problems in existing compounding policies and procedures
•    Train personnel on the correct use of PPE and aseptic techniques
•    Ensure the physical environment meets guidelines for cleaning and documentation
•    Ensure the proper labeling, dating, and sterility of compounded products

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