Personal Hygiene and Garbing
Non-Sterile Compounding <795>

Purpose/ Applicability:  To provide guidelines for practices such as hand hygiene and proper garbing. Personnel must perform hand hygiene before handling and performing non-sterile compounding. When handling and compounding hazardous drugs, PPE (required minimum: an N95 mask and exam gloves) must be donned appropriately. 

Scope: Applies to all personnel who handle non-sterile compounding.

Definition(s): N/A

Equipment:

• PPE

Procedure:

Guidelines:
1. Personnel engaged in compounding will maintain good general hygiene practices and will prohibit eating and drinking in areas where drugs are handled. Personnel will also wear clean and non-restrictive clothing that is appropriate to perform compounding.

2. Personnel must perform hand hygiene before performing non-sterile compounding. Personnel will have nearby access to a sink, soap and single use towels. 

3. If personal garments, such as hand or wrist jewelry, piercings, ear buds or headphones will interfere with compounding or garbing, these must be removed prior to compounding.

4. Gloves must be worn during compounding and gloves must be changed if ripped, torn, punctured, etc. Additionally, gloves should be wiped or changed between compounding with different components.