Personnel Training and Evaluation
Non-Sterile Compounding <795>

Purpose/ Applicability:  To provide training guidelines for personnel who will participate in non-sterile compounding.

Scope: Applies to all personnel involved in nonsterile compounding.

Definition(s): N/A

Equipment:

• N/A

Procedure:

1. Training involves personnel to read and be familiar with USP 795 and understand Safety Data Sheets.
2. Staff will need to be familiar with each of the compounding procedures, including those involving the:
   a. facility
   b. equipment
   c. personnel
   d. actual compounding
   e. evaluation
   f. packaging
   g. storage
   h. dispensing
3. Trainer will demonstrate procedures for the personnel, and will observe and guide personnel throughout the training process
4. Personnel will repeat procedures without assistance from, but under the direct supervision of the trainer.
5. Personnel must be fully trained in storage, handling and disposal of hazardous drugs prior to compounding hazardous drugs.
6. Personnel competency must be reassessed at least every 12 months and documented in the Personnel Training and Evaluation Annual Tracking document.