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Medication - Sterile Compounding - Testing/Certification Remediation Requirements for Primary and Secondary Engineering

If our Primary Engineering Control or Secondary Engineering Control certification/testing reports show a value outside of acceptable limits, what should we do?

Any examples are for illustrative purposes only.

Organizations are required to develop a remediation program to address the identified issue which must include retesting the tested components which were out of range. The remediation process should include an overall review of compliance with procedures including those of compounding staff, cleaning processes and products, and air filtration efficiency.  These should be evaluated to identify any potential adverse impact affecting testing results. 
 
Manual: Critical Access Hospital
Chapter: Medication Management MM
Last reviewed by Standards Interpretation: November 01, 2021 Represents the most recent date that the FAQ was reviewed (e.g. annual review).
First published date: January 23, 2018 This Standards FAQ was first published on this date.
This page was last updated on May 09, 2023 with update notes of: Review only, FAQ is current Types of changes and an explanation of change type: Editorial changes only: Format changes only. No changes to content. | Review only, FAQ is current: Periodic review completed, no changes to content. | Reflects new or updated requirements: Changes represent new or revised requirements.
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