USP  Compounding Cleanrooms

USP 800 Cleanroom Standards Overview

USP 800 establishes enforceable standards for the safe handling of hazardous drugs (HDs) to protect healthcare workers, patients, and the environment. Although initially published in 2016, USP 800 became official and enforceable on December 1, 2019, and remains in effect today. While USP 800 is a national standard, each state board of pharmacy determines how and when the chapter is adopted and enforced, so facilities should always verify state-specific requirements and consult qualified cleanroom professionals when planning upgrades.

Unlike USP 797 and USP 795, which underwent further revisions and an official update in 2022/2023, USP 800 has not been revised since its adoption. However, facilities must now implement USP 800 alongside the updated 2023 USP 797 requirements, which impact workflow, engineering controls, certification, and environmental monitoring expectations.

USP 800 applies to all stages of hazardous drug handling and includes requirements for:

  • Receipt and unpacking of hazardous drugs
  • Storage of hazardous drugs under appropriate containment
  • Nonsterile hazardous drug compounding (when performed)
  • Sterile hazardous drug compounding (when performed)

These requirements include specifications for facility design, Containment Primary and Secondary Engineering Controls (C-PEC/C-SEC), room pressurization, airflow, personal protective equipment (PPE), environmental monitoring, spill control, and decontamination procedures.

To ensure full compliance, facilities should undergo a detailed assessment of their engineering controls, HVAC capacity, workflow design, and HD handling processes. Partnering with a cleanroom engineer or USP compliance specialist is highly recommended, particularly when upgrading an existing USP 797 cleanroom to meet USP 800 containment standards.

General Chapter <800>

USP 800 expands controls for the protection of workers and environments against hazardous drug compounds. In contrast to USP 797, which only remedies sterile compounding activities, USP 800 takes a 360-degree approach for processing hazardous drugs. Its predecessor, USP 797, is narrower in scope, and focused on sterile compounding preparations. USP 800 defines new controls over compounding environments and equipment that apply to both sterile and non-sterile compounding, hazardous and non-hazardous. The USP 800 compliance deadline accompanies a USP suggestion for early organizational adoption. Diligent protection of healthcare practitioners and others when handling hazardous drugs is a clear priority. Achieving new standards set forth by USP 800 may require retrofitting an existing structure, which is where consulting a team of architects and engineers is ideal.

USP 800 STD Hazardous Compounding Risk Assessment

The takeaway from USP 800 cleanroom requirements is that exposing workers to hazardous compounds is not an acceptable risk. USP 800 environments mitigate the risk of harm to both the environment and workers when compounding or packaging hazardous drugs. That could include antineoplastic drugs, hormonal therapies, radiopharmaceuticals, bacteria, and viruses. Primarily, negative pressure cleanrooms and dedicated ventilation systems account for the greater portion of improved safety and thus the majority of required changes.

USP 800 compliant cleanrooms protect healthcare personnel, patients, and the environment when handling hazardous drugs as seen on the NIOSH hazardous-drug list. In contrast to USP 797, which upgrades process controls of sterile compounds, USP 800 expands specifically on the compounding of hazardous drugs (HDs).

Basic Requirements for USP 800 Cleanroom Compliance

Connected, adjacent cleanroom designs with negative pressure and exhaust containment systems prevent contaminated air from recirculating or escaping when mixing HDs, both sterile and non-sterile. USP 800 requires external venting within the primary engineering controls for hazardous drugs, and will have the most impact on facilities handling both hazardous and nonhazardous drugs.

Not Sure What You Need for USP 800?

For some healthcare facilities, upgrading or retrofitting a cleanroom for USP 800 compliance requires infrastructural and mechanical modifications. Small modifications may include equipment upgrades while more extensive upgrades may include expanding cleanrooms, new ductwork, and dedicated exhaust systems. Learn more.

1 thought on “USP <800> Compounding Cleanrooms”

  1. You make a great point that USP 800 expands the safety of healthcare workers and the environment when processing drugs that can be hazardous. I like that you say this standard makes sure that workers are not exposed to hazardous compounds and requires clean rooms to avoid circulating contaminated air. My sister works at a pharmacy and this cleanroom standard gives me peace of mind that she will be as safe as possible when working.

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