SOP-003 / SOP v2.0
Training, hygiene and clothing
Staff, visitors and contractors entering the compounding area.
Procedure
- Define permitted tasks for each role. Initial training covers SOPs, calculations, records, cleaning and incident response.
- Assess competency through observation and documented practice work. Reassess after significant changes or errors.
- Perform hand hygiene before entry, after contamination and when changing activities. Exclude food, drinks and personal items.
- Wear clean laboratory clothing and hair covering. Select gloves and eye/respiratory protection from SDS and task risk assessment.
- Change gloves and contaminated clothing between incompatible tasks. Gloves do not replace hand hygiene.
- Report health conditions or sensitisation affecting safe work confidentially to the designated responsible person. Assign suitable alternative tasks.
Edition-specific detail
F-011 records task-specific training and observed competence: weighing, independent calculation, cleaning, deviation handling and safe PPE removal. Reading an SOP alone does not establish practical competence. Reassess the affected task after a significant change or observed error.
Stop criterion
Untrained staff or unsuitable PPE: no unsupervised compounding.
Related forms
Sources and references
- NAPRA — Model Standards for Pharmacy Compounding of Non-sterile PreparationsMarch 2018, clarification January 2022Sections 4–9Risk, personnel, facilities and QA; its historical BUD table is not used for current USP defaults2026-09-12
- NAPRA — Guidance Document for Pharmacy Compounding of Non-sterile PreparationsMarch 2018, clarification January 2022Sections 5, 6 and 7; master/batch records, delivery, qualityQuality-system implementation; historical BUD table not substituted for 2022 USP revision2026-09-12
- PIC/S — Guide to Good Practices for the Preparation of Medicinal Products in Healthcare EstablishmentsPE 010-4, 1 March 2014Chapters 1–9; Annex 2 (nonsterile liquids, creams, ointments)Professional quality-system framework; not automatic national legal adoption or certification2026-09-12