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Compounding within your facility’s capabilities

April 29, 2020

The first two priorities of non-sterile compounding standards must be met.

The implementation deadline for priority three requirements of the ACP Standards for Pharmacy Compounding of Non-sterile Preparations have been extended to July 1, 2021. The deadline was extended because of delays that are outside of pharmacy licensees’ control arising from the COVID-19 pandemic. 

Still, licensees must continue to be engaged in preparing their pharmacy to comply with priority three requirements prior to the new implementation deadline, as an additional extension should not be anticipated.

While priority three requirements focus primarily on facilities and equipment, it is important for compounders to remember that priority one and priority two requirements must still be met. The ACP non-sterile compounding standards and guidelines remain in effect. This means that compounding should only occur based on your facility’s capabilities and your risk assessments completed for the compounds you prepare. This will help ensure staff and patient safety, and the quality of compounded preparations.

Provision of non-sterile compounding services may also be addressed by entering into a compounding and repackaging agreement with a pharmacy that meets the standards. Pharmacies planning renovations should submit an application for renovation to ACP to ensure that they meet the standards.

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