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The Joint Commission has made their focus for 2018 clear. In a notice to all accredited hospitals TJC stated that sterile medication compounding, regulated by USP 797, will be a focus for surveys.


Despite increased regulations, incidents of contamination continue to occur in hospitals across the US. Consequently, hospitals can expect TJC survey teams to take a deep look and spend extra time evaluating all areas of compliance with current USP 797 regulations, including remote ambulatory settings.


We've found that current USP 797 standards are more stringent than the measures most hospitals typically take to prevent contamination of sterile medications. If you're concerned that your hospital's compliance status with USP 797 wouldn't stand up to scrutiny during a survey, EH&E's team of healthcare compliance experts can help. Our team has extensive experience with both USP and Joint Commission compliance. We can help you quickly get into compliance so that you are "survey ready".


How We Can Help

  • USP 797/800 compliance gap assessments
  • Feasibility studies and proven compliance strategies
  • Risk-based environmental monitoring programs
  • Training
  • Hazardous drug safety programs
  • Development of facility and engineering controls
  • Cleanroom design review and equipment validation

Contact David Shore for more information at 800-825-5343 or

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