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usp795 non-sterile compounding compliance guide

SOSCleanroom Education Center
USP <795> Non-Sterile Compounding
A practical white paper on consumer safety benefits, operational compliance pillars, and execution tools that help teams stay consistent and audit-ready

Last updated: January 2026
By: SOSCleanroom

Non-sterile compounding basics for pharmacies, hospitals, clinics, and new technicians

USP <795> overview Consumer safety CNSPs and quality basics BUD and labeling discipline Cleaning and documentation Customer checklist

USP <795> is a U.S. Pharmacopeia–National Formulary (USP–NF) General Chapter that establishes minimum standards for compounding non-sterile preparations (often called compounded non-sterile preparations, or CNSPs). The purpose is straightforward: reduce preventable patient harm by controlling contamination, ingredient variability, dosing errors, mix-ups, and process drift that can occur when non-sterile preparations are compounded.

Important note on sources: USP standards are copyrighted. This SOSCleanroom white paper is an educational, operational interpretation written in plain language. It does not reproduce USP–NF text verbatim and is not a substitute for the official USP–NF chapter. Always consult the official USP–NF text and your jurisdiction’s adoption/enforcement requirements for definitive requirements.
In one sentence: USP <795> protects patients by requiring non-sterile compounding to be performed using trained personnel, controlled components and equipment, standardized processes, and defensible documentation—especially around formulation, beyond-use dating, labeling, storage, and quality checks.

1) Executive summary

USP <795> should be viewed as a system, not a single task. Strong programs align six elements: (1) governance and quality oversight, (2) trained and qualified personnel, (3) suitable facilities and equipment, (4) controlled component selection and handling, (5) standardized compounding and cleaning practices, and (6) controlled packaging/labeling/storage and beyond-use date (BUD) discipline.

What “good” looks like
  • Every batch is compounded the same way (weights, measures, order of addition, mixing method, and time are standardized).
  • Components are controlled (identity, grade, storage, and expiration are verified and documented).
  • BUDs and labels are consistent (rationale is documented and tied to risk and stability basis).
  • Records are complete and audit-ready (you can prove what happened and why).
What causes most compliance failures
  • Variation: different mixing techniques, weighing habits, or shortcuts across staff.
  • Weak component control: missing CoAs where needed, unclear lot traceability, poor storage discipline.
  • Inconsistent BUD assignment: unclear rationale, missing documentation, or mismatched labels.
  • Incomplete documentation: missing batch records, cleaning logs, or review cadence.

2) How USP <795> benefits consumers

Patients rarely see the compounding environment, but they experience the outcomes. USP <795> improves consumer safety by requiring disciplined controls that reduce the likelihood of:

  • Contamination: microbial, cross-contamination between products, allergens, and foreign material.
  • Strength variability: inconsistent weighing/measuring and mixing can yield unpredictable potency.
  • Mix-ups and labeling errors: incorrect instructions, concentration, or patient-specific labeling details.
  • Instability and degradation: inappropriate BUDs or storage conditions can reduce effectiveness or change product performance.
  • Loss of traceability: inability to investigate and correct issues rapidly if something goes wrong.

3) Core compliance pillars (operational)
Practical rule: If you reduce variation, you reduce risk. Most compliance work is “process engineering” for humans—making the right action the easiest action.
A) Governance and quality system
  • Assign responsibility for non-sterile compounding oversight and record review (clear ownership prevents drift).
  • Control SOPs: versioning, approvals, change control, and accessible training artifacts.
  • Manage deviations and CAPA: investigate excursions, document root cause, and record corrective actions.
  • Maintain audit readiness: if it is not documented, it is difficult to defend.
B) Personnel, hygiene, and workflow discipline
  • Train to a single best method for weighing/measuring, mixing, and documentation steps.
  • Define hygiene and attire expectations appropriate to the activity and risk level.
  • Design workflow to prevent mix-ups: clear staging, labeled intermediates, and one-batch-at-a-time habits where practical.
  • Standardize supply staging so staff do not improvise.
C) Facilities, equipment, and component control
  • Use suitable designated areas that support cleanliness, organization, and controlled access during compounding.
  • Maintain equipment suitability: calibration/verification where needed and documented maintenance.
  • Control components: identity, grade, labeling, storage, and expiration; keep lot traceability in records.
  • Control material flow to prevent cross-contamination and allergen transfer.
D) Cleaning, sanitation, documentation, and BUD discipline
  • Define cleaning frequencies, chemistries, and methods; document completion and review logs routinely.
  • Standardize wipe technique: direction, overlap, face control (folding/rotation), and change-out rules.
  • Ensure labeling and packaging are controlled and consistent with the batch record and counseling needs.
  • Document BUD rationale and storage expectations consistently; align labels, records, and internal references.

4) SOSCleanroom execution tools that support USP <795>

USP <795> compliance is won in day-to-day execution: accurate measuring, consistent mixing technique, controlled components, clean work surfaces, and documentation that matches what actually happened. SOSCleanroom supports customers by providing cleanroom-grade consumables and practical guidance to help teams build repeatable programs.

Non-endorsement clarity: USP does not endorse specific brands or products. The examples below are provided to help customers map “requirement → execution tools” inside their SOPs and validation expectations.
Program need Typical execution tools SOSCleanroom examples
Worksurface wipe-downs and routine sanitation 70% IPA solutions or pre-wetted wipes + low-lint wipers appropriate to the surface and residue sensitivity Texwipe TX167 non-sterile 70% IPA solution (USP-grade)
Texwipe TX8727 pre-wetted 70% IPA wipers
Browse cleanroom wipers
Precision cleaning of small surfaces and hard-to-reach areas Cleanroom swabs for controlled application of solutions and targeted wipe-down Browse cleanroom swabs
Texwipe TX701 (example)
Barrier PPE and reduced handling Cleanroom gloves and dispensing formats that support workflow discipline Cleanroom gloves (category)

5) USP <795> customer checklist
Disclaimer
These checklists are provided by SOSCleanroom for general educational use and operational planning only. They are recommendations and do not constitute legal, regulatory, clinical, or safety advice, and should not be treated as a statement of fact about your specific facility. SOSCleanroom does not certify compliance through this document. You are responsible for developing, approving, and maintaining your own SOPs, training, documentation, and validation based on the official USP–NF text, your state/federal requirements, and your organization’s risk assessment. Always consult qualified professionals and the applicable authorities having jurisdiction (AHJ).

Use this checklist for a rapid internal self-assessment. Align each item to the currently applicable USP–NF official text and your jurisdiction’s enforcement posture. This checklist is designed to be operationally useful without quoting USP text.

Printable Resource
USP <795> Customer Checklist (PDF)
Matches the on-page disclaimer and checklist format.
Note: After opening the PDF, use your browser/PDF viewer print icon to print.
A) Governance and quality system
B) Personnel and workflow discipline
C) Components, cleaning, and documentation basics

6) Official USP references

Use the official USP resources below as your source of truth for requirements, official dates, and the current chapter text pathway.

  • USP compounding resource portal (General Chapter <795>): https://www.usp.org/compounding/general-chapter-795
  • USP–NF notice on publication/official date of revised <795>: https://www.uspnf.com/notices/795-pub-announcement-20221101
  • USP FAQ — Identifying “official text” in USP–NF: https://www.usp.org/frequently-asked-questions/identifying-official-text
  • USP FAQ hub: https://www.usp.org/frequently-asked-questions

Need help selecting consumables that support your non-sterile compounding program?

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SOSCleanroom Education Center
SOSCleanroom is the source for this educational entry.
Briefed and approved by the SOSCleanroom (SOS) staff.
Questions? Contact our team.

Last reviewed: January 22, 2026 Customer-first, audit-ready guidance Cleanroom consumables + education
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