Usp 797 guidelines beyond use dating Sterile Compounding Pearls of Knowledge – August 2017 Edition

Usp 797 guidelines beyond use dating

Under aseptic conditions and using aseptic techniques, affix a sterile 0. The pharmacy should have written, properly approved standard operating procedures SOPs designed to ensure the quality of the environment in which a CSP is prepared.

In addition, operations using nonsterile components require the use of a method of preparation designed to produce a sterile product. A written description of specific training and performance evaluation program for individuals involved in the use of aseptic techniques for the preparation of sterile products must be developed for each site.

Establishing, maintaining, and assuring compliance with comprehensive written policies and procedures encompassing these responsibilities is a further responsibility of the pharmacy. Before processing CSPs, hands are resanitized after donning all appropriate garb, except for gloves.

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The use of tamper-proof closures and seals on CSP ports can add an additional measure of security to ensure product integrity regardless of transport method used. Faucet handles are designed to be hands-free. Nonsterile preparations are terminally sterilized but are not tested for bacterial endotoxins.

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In addition, the patient and the physician of the patient to whom a potentially contaminated CSP was administered is notified of the potential risk.

Dust-collecting overhangs, such as ceiling utility pipes, or ledges, such as windowsills, should be avoided. Tasks carried out within the buffer area should be limited to those for which a controlled environment is necessary.

For a low-risk preparation, in the absence of passing a sterility test, the storage periods cannot exceed the following time periods: For volume accuracy, a suitable volume of Sterile Water for Injection, which represents a typical additive volume e. Compounding personnel are responsible for ensuring that CSPs are accurately identified, measured, diluted, and mixed; and are correctly purified, sterilized, packaged, sealed, labeled, stored, dispensed, and distributed.

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Identification of appropriate follow-up mechanisms when action limits or thresholds are exceeded; and. Respond immediately to emergency or critical situations such as guideline beyond use dating breakage or displacement, tubing disconnection, clot formation, flow blockage, and equipment malfunction.

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No shipping or other external cartons may be taken into the buffer or clean area. The licensed health care professionals who supervise compounding are responsible for determining that the selected sterilization method see Methods of Sterilization under Sterilization and Sterility Assurance of Compendial Articles both sterilizes and maintains the strength, purity, quality, and packaging integrity of CSPs.

All compounding personnel are trained in and educated about the importance of this environmental monitoring process. Media-fill test procedure performed at least annually for each person.

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These vials are the controls, and they generate exponential microbial growth, indicated by visible turbidity upon incubation. However, the methods in such laboratories are often designed for biological, not pharmaceutical, systems. Visual inspection of CSPs to ensure the absence of particulate matter in solutions, the absence of leakage from vials and bags, and the accuracy and thoroughness of labeling.

CSPs compounded under any of the following conditions are either contaminated or at a high risk to become contaminated with infectious microorganisms.

Transfer of volumes from multiple ampuls or vials into a single, final sterile container or product. The patient or caregiver is expected to demonstrate to appropriate health care personnel their mastery of their assigned activities before being allowed to administer CSPs unsupervised by a health professional.

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Use and storage Written policies and procedures. Compounding personnel are adequately skilled, educated, instructed, and trained to correctly perform and document the following dating site jordan in their sterile compounding duties: Items that are not directly exposed to pressurized steam may result in survival of microbial organisms and spores.

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The DCCA is shielded from all less clean air currents that are of higher guideline beyond use dating than the clean laminar airflow. The risk of such a site picking up contamination from the environment increases with time of exposure. Supplies to be utilized in the DCCA for the planned procedures are accumulated and then decontaminated by wiping or spraying the outer surface with IPA or removing the outer wrap at the edge of the DCCA as the item is introduced into the aseptic work area.

All CSPs that are not used as originally intended must be returned to the pharmacy for appropriate disposition, which may include redispensing, but only if adequate continuing quality can be fully ensured.