Manual: Home Care
Chapter: Medication Compounding MC
Topic: Medication - Sterile Compounding - Nurse Competency Requirements (USP 797 2008 Version Only)

Are we required to do Finger Tip Testing and Media Fill Testing on nurses who compound emergent-use items outside of the pharmacy ?

Any examples are for illustrative purposes only.

No, immediate-use compounding is reserved for situations where an immediate/urgent need for medications is present and a delay in waiting for the pharmacy to compound items could delay care, as well as items with limited stability, once compounded.  Therefore, The Joint Commission will not require fingertip or media fill competencies for nurses  performing  immediate-use compounding outside of the pharmacy.
Last updated on November 05, 2024 with update notes of: Editorial changes only
First Published Date: January 23, 2018
Last Reviewed Date: April 19, 2022