Is your surgery center using a hood? If so, have you done a full assessment to ensure you are compliant with USP 797?
We know that the newest version of USP 797 was recently released and has an enforcement date of November 1, 2023. Although it seems like a long way from now, it doesn’t mean you should wait. You can do several things now to ensure you will be compliant by November.
For ambulatory surgery centers using a hood in a segregated compounding area, there are many requirements to pay attention to. Some requirements must be met prior to starting and others must be met on an ongoing basis. Have you developed a checklist of requirements? How will you ensure both your facility, and your staff will be compliant?
Using a hood can provide some conveniences in an ambulatory surgery center, but is it worth the cost? What are the costs? Sure, there is the actual cost of the hood, but have you considered the hundreds of hours involved in attaining and maintaining compliance?
If you decide to use a hood, you will need to develop, maintain, and enforce facility policies and procedures in several areas highlighted by 797. Our clients will be receiving a complete USP 797 checklist during our upcoming visits. The checklist will address key questions that must be answered and itemize the chapter requirements to facilitate compliance.
Ultimately, you will have to make this decision by doing a careful analysis of the factors impacting your facility. Your decision should ultimately come down to what is in the best interest of patient safety, followed by what is the best financial decision. Work with your pharmacy consultant to make an informed decision. If you have questions about this topic, or if you need an expert pharmacy consultant, we are here to help you.
The Consultant Pharmacists at OctariusRx provide guidance on safe medication management, survey readiness and cost savings to ambulatory healthcare facilities/surgery centers, senior care facilities and pharmacies. We also help individual patients optimize their medications to improve their quality of life and save money. Contact us for assistance.