The Gap Analysis and Action Plan

Abstract

Abstract-USP <797> is the culmination of the pharmacy professions’ low adoption of “recommended” Compounded Sterile Products’ (CSPs) guidelines and medication compounding incidents that were a result of these preparation practices. Currently, the Joint Commission on Accreditation of Health care Organizations (JCAHO) expects accredited health care agencies to comply with the provisions within USP <797>. This article depicts the Gap Analysis and subsequent Action Plan of a Level 1 trauma, academic medical center's structural and operational processes for the preparation of CSPs. The objective of this article series is to increase awareness, resources, and the body of information available for facilities’ assessing and strategically planning compliance and implementation of USP <797>.

Keywords

USP Chapter <797>compounded sterile products (CSPs)JCAHO Gap Analysis Action Plan

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