Report Summary

Title: Combined Assessment Program Summary Report – Evaluation of Compounded Sterile Product Practices in Veterans Health Administration Facilities
Report Number: 16-03807-223
Issue Date: 5/10/2017
City/State:
VA Office: Veterans Health Administration (VHA)
Report Author: Office of Healthcare Inspections
Report Type: CAP Reviews
Release Type: Unrestricted
Summary: The VA Office of Inspector General completed a healthcare inspection of compounded sterile product (CSP) practices in Veterans Health Administration facilities. The purpose of the review was to determine whether facilities complied with selected requirements for the safe preparation of CSPs. CSPs are pharmaceutical preparations made or modified in a controlled sterile environment. We conducted this review at 25 Veterans Health Administration medical facilities during Combined Assessment Program reviews performed across the country from October 1, 2015, through March 31, 2016. We noted high compliance in several areas, including that facilities had adequate policies and provided safe conditions for CSP preparation; that staff documented sampling for contamination in required areas and took actions when they identified positive cultures; and that when facilities used non-VA sources for CSPs, the sources were appropriately registered. We made five recommendations.