Chapter Phar 15

Phar 15.015(17) (17) “Refrigerator” means a cold place in which the temperature is maintained between 36 degrees and 46 degrees Fahrenheit or 2 degrees and 8 degrees Celsius.

Phar 15.015(18) (18) “Stability” means the extent to which a compounded preparation retains, within specified limits and through its beyond use date, the same properties and characteristics that it possessed at the time of compounding.

Phar 15.015(19) (19) “Therapeutic stability” means the therapeutic effect remains unchanged.

Phar 15.015(20) (20) “Toxicological stability” means no significant increase in toxicity occurs.

Phar 15.015(21) (21) “USP” means the United States Pharmacopeia.

Phar 15.015 History History: CR 16-085: cr. Register April 2018 No. 748 eff. 11-1-18; CR 22-007: am. (11), (13), (17) Register July 2022 No. 799, eff. 8-1-22.

Subchapter I — General

Phar 15.10 Phar 15.10 Facilities. A pharmacist engaged in compounding shall ensure all of the following:

Phar 15.10(1) (1) An area designated for compounding.

Phar 15.10(2) (2) Orderly placement of compounding equipment, materials, and components in order to minimize the potential for compounding errors.

Phar 15.10(3) (3) The compounding area is maintained in a clean and sanitary condition.

Phar 15.10(4) (4) The compounding area is easily accessible to all of the following:

Phar 15.10(4)(a) (a) Hot and cold running water, exclusive of the bathroom sink.

Phar 15.10(4)(b) (b) Soap or detergent.

Phar 15.10(4)(c) (c) Single-use towels.

Phar 15.10(5) (5) All compounding equipment, materials, and components shall be stored off the floor and in a manner to prevent contamination and permit inspection and cleaning of the compounding and storage areas.

Phar 15.10 History History: CR 16-085: cr. Register April 2018 No. 748 eff. 11-1-18.

Phar 15.11 Phar 15.11 Equipment and Drug Preparation Containers.

Phar 15.11(1) (1) A pharmacy shall possess equipment and drug preparation containers or packaging appropriate to the type of compounding performed at the pharmacy.

Phar 15.11(2) (2) Equipment and drug preparation containers or packaging used in compounding shall be of appropriate design and capacity, and shall be suitably stored in a manner to facilitate use, cleaning, maintenance, and protect it from contamination.

Phar 15.11(3) (3) Equipment and drug preparation containers or packaging used in compounding drug products shall be of suitable composition and may not be reactive, additive, adsorptive, or absorptive so as to alter the stability of the compounded preparation.

Phar 15.11(4) (4) Equipment used in compounding shall be thoroughly cleaned and sanitized after each use, and when necessary, prior to use, according to written policies and procedures, in order to reduce bioburden and reduce the opportunity for cross-contamination.

Phar 15.11(5) (5) All equipment utilized in compounding preparations shall be inspected, maintained, calibrated, and validated at appropriate intervals, consistent with manufacturer’s recommendations, to ensure the accuracy and reliability of equipment performance. Records shall be kept indicating the equipment was inspected, maintained, calibrated, and validated.

Phar 15.11 History History: CR 16-085: cr. Register April 2018 No. 748 eff. 11-1-18.

Phar 15.12 Phar 15.12 Records of compounding. The managing pharmacist shall ensure written or electronic compounding documentation to systematically trace, evaluate, and replicate the compounding steps throughout the process of a preparation. The compounding documentation shall be maintained for a period of 5 years after the date of the last refill. The compounding documentation shall include all of the following:

Phar 15.12(1) (1) Official or assigned name, strength, and dosage form of the preparation.

Phar 15.12(2) (2) List of all APIs and added substances and their quantities.

Phar 15.12(3) (3) Vendor or manufacturer, lot number and expiration date of each APIs and added substances.

Phar 15.12(4) (4) Equipment and supplies needed to prepare the preparation.

Phar 15.12(5) (5) Mixing instructions pertinent to the replication of the preparation as compounded.

Phar 15.12(6) (6) Compatibility and stability information, including references or laboratory testing.

Phar 15.12(7) (7) Container or container-closure system used in dispensing.

Phar 15.12(8) (8) Packaging and storage requirements.

Phar 15.12(9) (9) Quality control procedures.

Phar 15.12(10) (10) Sterilization method when using non-sterile ingredients to make a sterile preparation.

Phar 15.12(11) (11) Total quantity compounded.

Phar 15.12(12) (12) Name of the person who prepared the preparation.

Phar 15.12(13) (13) Name of the person who performed the quality control procedures.

Phar 15.12(14) (14) Name of the person who approved the preparation.

Phar 15.12(15) (15) Date of preparation.

Phar 15.12(16) (16) Assigned control or prescription number.

Phar 15.12(17) (17) Assigned BUD.

Phar 15.12(18) (18) Copy of the label to dispense final product.

Phar 15.12(19) (19) Documentation of any adverse reactions or preparation problems reported by the patient or caregiver.

Phar 15.12 History History: CR 16-085: cr. Register April 2018 No. 748 eff. 11-1-18.

Phar 15.13 Phar 15.13 Quality control.

Phar 15.13(1) (1) One or more pharmacists shall complete a verification of all the following before dispensing:

Phar 15.13(1)(a) (a) Written procedures were followed in the compounding process.

Phar 15.13(1)(b) (b) Preparation instructions were followed.

Phar 15.13(1)(c) (c) Finished preparation appears as expected.

Phar 15.13(1)(d) (d) Label includes all required elements.

Phar 15.13(1)(e) (e) Quality control procedures were completed.

Phar 15.13(1)(f) (f) Compounding records are complete.

Phar 15.13(2) (2) A pharmacist shall investigate any discrepancies found during any of verifications and take appropriate corrective action before dispensing.

Phar 15.13 History History: CR 16-085: cr. Register April 2018 No. 748 eff. 11-1-18.

Phar 15.14 Phar 15.14 Training, Policies, and Procedures.

Phar 15.14(1) (1) Training. All personnel involved in the compounding, evaluation, packaging, and dispensing of compounded preparations shall be properly trained and competency is assessed for the type of compounding conducted. It is the responsibility of the managing pharmacist to ensure personnel training and competency assessments are completed and documented.

Phar 15.14(2) (2) Policies and procedures. The pharmacy and managing pharmacist shall establish written policies and procedures governing all of the following:

Phar 15.14(2)(a) (a) Personnel qualifications and training, responsibilities, and competencies.

Phar 15.14(2)(b) (b) Personal hygiene, garb, garbing, and personal protective gear.

Phar 15.14(2)(c) (c) Use and maintenance of compounding facilities and equipment, including applicable certifications.

Phar 15.14(2)(d) (d) Environmental monitoring.

Phar 15.14(2)(e) (e) Cleaning and disinfection of compounding area.

Phar 15.14(2)(f) (f) Component selection.

Phar 15.14(2)(g) (g) Sterilization and depyrogenation, if pharmacy does sterilization and depyrogenation.

Phar 15.14(2)(h) (h) Documentation requirements.

Phar 15.14(2)(i) (i) Establishing BUD.

Phar 15.14(2)(j) (j) Reporting of adverse drug events.

Phar 15.14(2)(k) (k) A risk management program, including documentation of incidents, adverse drug reactions and product contamination.

Phar 15.14(2)(L) (L) A quality assurance program.

Phar 15.14(2)(m) (m) Maintaining the integrity of any classified work areas.

Phar 15.14(2)(n) (n) Handling small and large spills of antineoplastic agents and other hazardous substances.

Phar 15.14(2)(o) (o) Notification to patients or practitioners of a preparation which is recalled when there is potential for patient harm.

Phar 15.14(3) (3) Review of policies and procedures. The policy and procedures shall be reviewed at least once every 36 months and shall be updated, on a continuous basis, to reflect current practice. Documentation of the review shall be made available to the board upon request.

Phar 15.14 History History: CR 16-085: cr. Register April 2018 No. 748 eff. 11-1-18; correction in (2) (o) made under s. 35.17, Stats., Register April 2018 No. 748.

Phar 15.15 Phar 15.15 Labeling. The label of a compounded preparation shall include all of the following:

Phar 15.15(1) (1) Labeling requirements in s. Phar 7.02 and 8.08.

Phar 15.15(2) (2) Storage conditions if other than controlled room temperature.

Phar 15.15(3) (3) BUD.

Phar 15.15(4) (4) Special handling instructions, when applicable.

Phar 15.15(5) (5) Indication that the preparation is compounded unless administered by health care personnel.

Phar 15.15 History History: CR 16-085: cr. Register April 2018 No. 748 eff. 11-1-18.

Phar 15.16 Phar 15.16 Component Selection.

Phar 15.16(1) (1) Active pharmaceutical ingredients or added substances used in compounding shall be manufactured by an FDA registered facility or accompanied by a certificate of analysis.

Phar 15.16(2) (2) APIs and added substances shall meet USP or NF monograph specifications when monographs are available. A pharmacist shall use professional judgement in selection of APIs if USP or NF grade is not available.

Phar 15.16(3) (3) All components shall be stored and handled consistent with the manufacturer’s labeling or USP or NF monographs and in a manner that prevents contamination and deterioration.

Phar 15.16(4) (4) A pharmacist compounding for human use may not use components that have been withdrawn or removed from the market for safety or efficacy reasons by the FDA. A pharmacist compounding for food producing animal use may not use components prohibited for use in food producing animals.

Phar 15.16 History History: CR 16-085: cr. Register April 2018 No. 748 eff. 11-1-18.

Phar 15.17 Phar 15.17 Non-patient specific compounding. Compounded preparations dispensed or distributed to a practitioner pursuant to a non-patient specific order to be administered by a practitioner or practitioner’s agent shall meet all of the following: