"Non-Sterile Compounding: Training, Competency & Decision-Making" for Pharmacy Technicians In Practice

Why this matters to you

Every compound you prepare impacts patient safety, regulatory compliance protects your license and your pharmacy, competency = Confidence in your work, Mistakes can mean harm to patients and disciplinary action

Training programs

You must complete hands-on and theory-based training before compounding, training is tailored to your role, measuring and weighing, mixing and blending and documentation and labeling…

Training log

Tip: Keep your ________ up to date, inspectors will ask for it..

Skills assessment

Regular check-ins to prove you can: follow SOPs exactly, use equipment correctly, maintain cleanliness standards, if you make an error, collective training is documented, this protects you and the patient…

Policies & Procedures

SOPs are your recipe book + safety manual, must be: clear and easy to follow, accessible in the lab, reviewed every 3 years or sooner if rules change, and Hazardous drug SOPs = extra PPE, containment, and disposal steps…

Facility requirements

Dedicated compounding space, no clutter, no food, no distractions, storage off the floor, labeled and organized, surfaces that can be wiped down easily, good lighting so you can see powders and liquids clearly, HVAC that keeps ingredients stable and air clean, and hot and cold running water nearby…

Equipment requirements

Use the right tool for the job (e.g. mortar & pestle vs. ointment mill), clean after every use, even if it looks clean, Keep calibration logs for balances and thermometers, Dedicated tools for hazardous vs. non-hazardous compounding…

Decision to compound

Before you start ask; Is it clinically needed? Is there a commercial product? Do we have a validated formula, what is the risk level (A, B, C)? Do we have the space, tools, and ingredients? Are trained staff available? Can we document everything? If not should we refer it?

Yes it can be compounded

Scenario: Pediatric patient allergic to preservatives in commercial lidocaine patches. Based on the below info, do we compound the product?

Clinical need? Yes

Commercial alternative suitable? No

Formula available? Yes

Risk level: B - semi-solid w/ active drug

Space, tools, ingredients? Yes

Trained staff? Yes

Technician takeaways

Your role is hands-on patient safety, follow SOPs like a recipe, no shortcuts, keep training and competency up to date, speak up if something feels unsafe or unclear and document everything, if its not written down, then it did’nt happen!

Federal

Bulk is ______….

Provincial

Compounding is _______…

Commercially available

We’ll never make something that is already ________ like acetaminophen…