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Press Release

ASHP, JCAHO to Convene Expert Panel on USP Compounding Requirements

The American Society of Health-system Pharmacists (ASHP) will advise the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) on the most important areas on which its surveyors should focus when evaluating the pharmacy compounding operations in hospitals and health systems at a meeting next week at JCAHO headquarters in Oakbrook, Ill. 

Health-system pharmacists who are expert in compounding sterile medications (see roster below) will identify top-priority areas of the new United States Pharmacopeia Chapter <797>, Pharmaceutical Compounding, Sterile Preparations.  Chapter <797>describes requirements, procedures and operational examples for compounding sterile preparations.  The expert panel will also recommend workable timeframes for organizations to implement <797> standards and identify activities that JCAHO surveyors might consider as key markers of compliance.

JCAHO will begin surveying for compliance with Chapter <797> on July 1.  High-quality sterile compounding practices consistent with the <797> standards is a high-priority for health-system pharmacists, says ASHP Executive Vice President and CEO Henri R. Manasse, Jr., Ph.D., Sc.D.  “We are confident that pharmacists in hospital and health system settings will lead efforts within their organizations to help administrators and other health professionals understand the patient safety benefits of these new requirements and ensure that the necessary changes are implemented so that no patient is ever harmed by an improperly compounded sterile medication," he said.  “ASHP offered JCAHO the expertise of our members to ensure that their surveyors could identify the most important areas for compliance and have an understanding of what constitutes a reasonable timeframe for their implementation.”

ASHP is leading efforts to ensure that pharmacists are prepared to meet <797> requirements in their practice settings.  The Society’s recently published online reference, the ASHP Discussion Guide for Compounding Sterile Preparations, recommends ways practitioners can begin implementing the chapter’s requirements.  Four ASHP-published references, Principles of Compounding Sterile Preparations, Guidelines on Quality Assurance for Pharmacy-Prepared Sterile Products, including a video tape and workbook to accompany the guideline, and Sterile Product Preparation: A Multimedia Tool, are being revised to include information on compliance with Chapter <797>.  ASHP is also developing a compounding resource center for its Web site that will include guidelines, references, key links, and the Society’s compounding resources.

ASHP is the 30,000-member national professional association that represents pharmacists who practice in hospitals, health maintenance organizations, ambulatory care clinics, long-term care facilities, home care, and other components of health care systems. ASHP, which has a long history of medication error prevention efforts, believes that the mission of pharmacists is to help people make the best use of medicines.  Assisting pharmacists in fulfilling this mission is ASHP's primary objective.  The Society has extensive publishing and educational programs designed to help members improve their professional practice, and it is the national accrediting organization for pharmacy residency and pharmacy technician training programs.  For more information, visit ASHP’s Web site, or


JCAHO - ASHP Expert Advisory Committee on USP 797
June 3, 2004
Oakbrook, IL


Dept. of Veterans Affairs

Bruce R. Harrison, MS, R.Ph, BCOP

Clinical Pharmacy Specialist

Section of Hematology/Oncology

Veterans Affairs Medical Center

St. Louis, MO


Small Community Hospital

Brenda J. Halling, R.Ph.

Boone County Hospital

Perry, IA


Health-System-Based Home Infusion Company

Brian G. Swift, Pharm.D.

Jefferson Home Infusion

Philadelphia, PA 


Oncology Practice-Based Pharmacist

Cathy L. Sasser, R.Ph.

Atlanta, GA 


Mid-Size Community Hospital

Patrick E. Parker, MSP, R.Ph.

Director of Pharmacy

Lawrence Memorial Hospital

Lawrence, KS


Academic Health Center, Published Author on Sterile Compounding Practices

E. Clyde Buchanan, M.S.

Senior Director of Pharmacy,

Emory Healthcare

Atlanta, GA


Small, Critical Access, and Medium Size Hospitals

Patricia Kienle

Medication Safety Manager

CardinalHealth Pharmacy Management

Laflin, PA 


ASHP Commission on Credentialing

James A. Jorgenson

Director of Pharmacy

University of Utah Hospital

Salt Lake City, UT


Pediatric Hospital

Christine L. Pavlak, R.Ph.

Director of Pharmacy

Saint Louis Children’s Hospital

Saint Louis, MO


United States Pharmacopeia

Claudia C. Okeke, Ph.D.

Associate Director

Information and Standards Department

U.S. Pharmacopeia (USP)

Rockville, MD


American Society of Health System Pharmacists

Joseph H. Deffenbaugh, M.P.H., R.Ph.

CAPT U. S. Public Health Service (Retired)

Director, Public Health and Quality


Kasey K. Thompson, Pharm.D.

Director, Practice Standards and Quality Division

Director, Patient Safety


Joint Commission on Accreditation of Healthcare Organizations

Darryl S. Rich, Pharm.D., M.B.A

Associate Director

Surveyor Management and Development


Michael Jarema

Department of Standards


Mary McNeily

Standards Interpretation Group -RN/RX Practice Issues


Dean Samet

Standards Interpretation Group -Engineering/Facility Design