SOSCLEANROOM | NONSTERILE PHARMACEUTICAL COMPOUNDING
USP <795>: Build a Safer, More Consistent Nonsterile Compounding Program.
A practical reference for pharmacy leaders and technicians covering training, designated compounding space, cleaning schedules, equipment and ingredient controls, master formulation records, beyond-use dating, inspection readiness and better supply decisions.
Explore the Guide ↓ View the USP <795> Checklist →The essential distinction
USP <795> is a nonsterile compounding standard—not a general cleanroom certification.
USP General Chapter <795> Pharmaceutical Compounding—Nonsterile Preparations describes minimum quality practices for compounded nonsterile preparations (CNSPs) used in humans and animals. A preparation can be nonsterile without being acceptable to produce carelessly: identity, strength, physical quality, contamination prevention and reliable records still matter.
Do not equate USP <795> with ISO Class 5, USP <797>, or FDA-approved drug manufacturing. A pharmacy may need designated compounding space and process-specific containment, but not every nonsterile activity requires an ISO-classified cleanroom. Federal and state law, USP–NF standards, and accreditation or contractual obligations must be assessed separately.
What the chapter controls
How the preparation is made
What it does not establish
Sterility of the finished drug
Who owns the process
Facility leadership and quality
What supplies can do
Reduce operational variability
Determine applicability first
Which compounding activities fall under USP <795>?
USP <795> addresses preparation of compounded nonsterile preparations by combining, admixing, diluting, pooling, or otherwise altering drug products or bulk drug substances, including certain reconstitution beyond a manufacturer’s labeled directions. Work performed strictly according to the manufacturer’s approved labeling is generally distinguished from compounding under the chapter.
Community pharmacy
Individualized oral formulations
Hospital or health system
Nonsterile pharmacy preparations
Veterinary compounding
Animal-specific dosage forms
Topical and specialty work
Creams, gels and suppositories
Regulatory boundary: federal law governing human drug compounding (including applicable 503A/503B conditions), state board rules, and the pharmacy’s applicable standards must be independently reviewed. FDA explains that compounded medications are not FDA-approved and that outsourcing facilities are subject to different quality requirements than qualifying 503A compounders.
What changed in the revised chapter
2023 revisions strengthened training, governance, cleaning and written records.
The revised USP <795> became official November 1, 2023. The comparison below summarizes selected changes documented by the American Society of Health-System Pharmacists (ASHP); it is not a substitute for the official chapter.
| Control | Practical expectation in revised chapter | What to check in the facility |
|---|---|---|
| Designated responsibility | One or more responsible individuals oversee facility and personnel performance. | Named owners, role descriptions, training review and escalation paths. |
| Personnel competency | Initial training and demonstration of knowledge/competency; periodic re-evaluation at least every 12 months. | Role-specific assessments, dates, assessors and retraining actions. |
| Gloving and garbing | Gloves during compounding; additional garb based on task and contamination/exposure risk. | Hand-hygiene checks, glove change rules and PPE compatibility. |
| Compounding space | A designated nonsterile area with appropriate sanitation, storage and workflow control. | Segregated tasks, cleanable surfaces, controlled storage and documented cleaning. |
| Records | An MFR for each unique CNSP formulation and a CR for each preparation. | Approved master recipe, complete batch history and second-person review where required. |
| Release | Visual inspection before release/dispensing. | Defined acceptance and documented disposition including deviations. |
| Beyond-use dates | Water activity and product-specific stability guide date assignment. | Correct formulation category, shorter-date triggers and documented rationale. |
Source: ASHP USP <795> Key Changes. Always consult the current official USP–NF text for binding chapter wording.
Physical environment and workflow
A designated, well-controlled workspace matters more than an unnecessary ISO label.
A practical nonsterile compounding space supports accurate measurement, safe movement, easy cleanup and separation of simultaneous activities. Select surfaces that resist cleaning damage; control exposure of powders and other materials; keep components, containers and finished CNSPs identifiable and properly stored.
Define
Designated work boundaries
Organize
Unidirectional material movement
Verify
Environmental and storage conditions
Contain
Powder and exposure control
Maintain
Cleanable surfaces and plumbing
Document
Area status and corrective action
An adhesive entrance mat, shoe cover, bouffant or cleanroom garment may support a facility-specific contamination plan, but none should be portrayed as universally mandated by USP <795>. Select only controls that solve a defined problem and do not introduce new hazards.
A practical schedule
Clean first when necessary, then sanitize using qualified chemistry and documented frequencies.
Cleaning removes soil and drug residues; sanitizing reduces microbial burden on appropriate surfaces. These are related but distinct operations. Where performed as separate steps, cleaning precedes sanitizing. Apply the product at its specified concentration and wet-contact time and verify compatibility with equipment, finishes and residue-control procedures.
| Area | USP <795> routine-frequency framework | Important trigger or control |
|---|---|---|
| Work surfaces | Beginning and end of each shift on compounding days. | Also between CNSPs containing different components; after spills and suspected contamination. |
| Floors | Daily on days when compounding occurs. | Also after spills or suspected contamination. |
| Walls | When visibly soiled or contaminated. | Clean after spills or splashes; do not treat a more frequent facility SOP as a USP-wide mandate. |
| Ceilings | When visibly soiled or contamination is suspected. | Assess safety, access and protection of exposed materials before overhead cleaning. |
| Storage shelving | At least every three months. | Also after spills or suspected contamination. |
| Equipment or containment work surfaces | By equipment-specific instructions and between different formulations. | Follow applicable chapter tables, engineering-control procedures and any hazardous-drug requirements. |
Source control: these are summarized from implementation/inspection references for the 2023 revised chapter, including Illinois pharmacy self-inspection guide and Kentucky USP <795> inspection template. Confirm the full official tables and local rules before changing an SOP.
Create a cleaning record that answers six questions.
1. What
Surface or equipment ID
2. When
Date, shift and trigger
3. With what
Agent and tool
4. How
Technique and contact time
5. Who
Operator and verification
6. What next
Status or exception
Safety: alcohol-based products are flammable and not suitable for every surface or soil. Do not mix disinfectants or assume 70% IPA controls drug residues, hazardous drugs or bacterial spores. Follow the current label/SDS and the facility’s approved sanitation method.
Human factors
Hygiene, correct glove use and competency are active process controls.
Training should verify that operators can demonstrate—not merely recite—safe nonsterile compounding. The 2023 chapter strengthened initial qualification and re-evaluation expectations. Inspectors may compare the written SOP with actual hand hygiene, component handling, equipment cleaning, measuring and batch documentation.
Before entry
Check personnel suitability
Before gloving
Perform proper hand hygiene
During work
Protect between formulations
For each role
Demonstrate proficiency
At intervals
Requalify and retrain
For hazardous materials
Add exposure controls
A cleanroom glove can be appropriate for certain handling tasks, but glove sizing and material compatibility matter more than treating an ISO-class marketing description as a USP certification. See SOScleanroom Glove Sizing and Fit Guide.
Balances, mixers, spatulas and enclosures
The equipment must be suitable, maintained, cleaned and reproducible.
Equipment selection depends on accuracy, capacity, drug compatibility and the likelihood of cross-contamination. Separate the concepts of routine performance verification, manufacturer calibration and formal suitability evaluation. Record equipment identification in the batch history where the facility requires it.
Measurement
Balances and volumetric devices
Product contact
Mortars, pestles and spatulas
Powders
Containment and transfer
After use
Disassembly and cleaning
Validated processes
Swabbing vs. cleaning
Maintenance
Device service lifecycle
A manufacturer technical data sheet identifies product characteristics; it does not prove that a particular swab, solvent or device has been validated for your preparation or residue limit.
Ingredient control
Know the identity, source, grade and status of every component.
Component qualification starts before material enters the compounding room. Receiving should confirm the ordered substance, supplier, label, lot, expiration or retest information, packaging integrity and appropriate storage. Active pharmaceutical ingredients used in qualifying human 503A compounding are subject to specific federal source and certificate-of-analysis conditions.
| Control point | What to verify | Why it matters |
|---|---|---|
| Bulk drug substance | Qualified supplier, applicable USP–NF monograph/503A eligibility, valid COA and source requirements. | Prevents uncontrolled introduction of a component with uncertain identity, strength or legal status. |
| Other ingredients/excipients | Identity, grade, suitability, lot, expiry and expected formulation function. | Inactive ingredients can affect physical stability, preservation and patient tolerability. |
| Water and solvents | Specified grade and suitability for the formulation or equipment rinse; appropriate storage. | A cleaning-grade alcohol or water is not automatically acceptable as a formulation ingredient. |
| Container/closure | Material compatibility, closure integrity, intended dispensing method and labeling. | Can affect stability, dosing accuracy, leachables and assigned BUD. |
| Receiving exception | Damaged packaging, temperature excursion, missing COA or label discrepancy. | Place on hold pending documented disposition, not informal substitution. |
For qualifying 503A compounding from bulk drugs, refer to FDA: Bulk Drug Substances Used Under Section 503A.
Make traceability work
Master Formulation Records and Compounding Records serve different purposes.
MFR = approved recipe and method. CR = the actual execution record for the preparation. The revised chapter requires a Master Formulation Record for each unique compounded nonsterile formulation and a Compounding Record for each preparation. Make the workflow easy for the user but difficult to complete with missing or contradictory critical data.
| Master Formulation Record (approved instructions) | Compounding Record (actual batch evidence) |
|---|---|
| Preparation name, strength, dosage form and formulation reference. | Preparation identifier, preparation date/time as applicable, operator and reviewer. |
| Components and intended quantities, including relevant characteristics. | Actual component sources, lot numbers, quantities and any adjustments/deviations. |
| Equipment, materials and step-by-step method. | Equipment identification and evidence steps were completed per the workflow. |
| Container/closure specification and expected appearance. | Actual packaging, quantity yielded, in-process findings and final observations. |
| BUD rationale, storage and special labeling instructions. | Assigned BUD, labeling check, release disposition and traceability. |
| Expected QC steps and acceptance characteristics. | Actual checks, findings, investigations and disposition where applicable. |
Example: follow one lot from receipt to dispensing.
Prescription/order → verified formulation → approved component lots → balance/equipment checks → documented cleaning status → execution/measurements → inspection → label and BUD → release. A vertical trace is a useful audit method, not a claim that every inspection follows the same sequence.
Use controlled digital fields or clean, legible paper records with revision control. If a mistake is corrected, preserve a traceable correction rather than overwriting or obscuring the original entry.
Critical patient-safety topic
Beyond-use dates are not manufacturer expiration dates or automatic shelf lives.
A beyond-use date (BUD) is assigned to the compounded preparation using the appropriate formulation category, water activity, chemical/physical stability, microbial risk, container/closure compatibility and supporting information. In the absence of a USP–NF compounded preparation monograph or suitable formulation-specific stability information, the following default limits from the revised chapter provide the framework.
| Preparation type | Default BUD limit | Storage under default framework |
|---|---|---|
| Nonpreserved aqueous dosage form (aw ≥ 0.60) | 14 days | Refrigerator. |
| Preserved aqueous dosage form (aw ≥ 0.60) | 35 days | Controlled room temperature or refrigerator. |
| Nonaqueous oral liquid (aw < 0.60) | 90 days | Controlled room temperature or refrigerator. |
| Other nonaqueous dosage forms (aw < 0.60) | 180 days | Controlled room temperature or refrigerator. |
These are limits, not guaranteed stability claims. Use a shorter BUD where component expiry, physical or chemical instability, microbial concerns, container compatibility or process deviations warrant it. Approved monographs or appropriate stability data may provide a different basis subject to the official chapter. Do not assume every cream is a “35-day product” merely because it is semisolid; determine its relevant water activity and preservation status.
Category
Water activity (aw) is not % water
Preservation
Preservative added does not equal proven protection
Chemistry
Stability can be the limiting factor
Packaging
The container can change the decision
Process
Deviations can shorten or invalidate a BUD
Label
State both BUD and storage instructions
Compare USP educational presentation on <795> BUD categories and UConn School of Pharmacy: Nonsterile Compounding BUD Overview. The official chapter and the approved formulation remain controlling.
Quality and release
A complete batch record is necessary but not sufficient.
Before dispensing, verify that the compounded preparation matches the intended formulation and its quality expectations. The revised chapter identifies visual inspection before release; any additional testing is dictated by the formulation, the SOP, risk assessment and the applicable standards.
Visual
Color, uniformity and appearance
Measurement
Yield and dosage consistency
Label
Identity, directions and BUD
Quality event
Deviation, hold and decision
Traceability
Recall capability
Change
Controlled improvement
Compounded drug products are not FDA-approved; see FDA compounding Q&A. The guide should help practitioners strengthen controls, not imply that an ingredient label or supplier certificate guarantees the final CNSP.
Do not conflate chapters
USP <795>, <797> and <800> have different scopes.
| Standard / framework | Primary scope | Operational implication |
|---|---|---|
| USP <795> | Compounded nonsterile preparations. | Dedicated space, personnel and quality controls; no automatic ISO-class requirement. |
| USP <797> | Compounded sterile preparations. | Sterile compounding has different environmental, aseptic and monitoring requirements. |
| USP <800> | Hazardous-drug handling to protect personnel, patients and the environment. | Additional engineering containment, PPE, deactivation/decontamination and exposure controls as applicable. |
| FDA 503A / 503B and state rules | Different legal pathways and enforcement obligations. | Confirm facility status and applicable federal/state requirements separately from purchasing decisions. |
Do not assume ordinary 70% IPA or generic nitrile gloves are sufficient for hazardous drugs. Use a risk-based hazardous-drug program with the appropriate containment equipment, tested chemotherapy gloves where indicated, drug-specific deactivation/decontamination and labeled waste disposal. Cleaning a visible spill is not equivalent to rendering an exposure hazard safe.
For related education, see USP <797> Cleaning Solutions, USP <800> Hazardous-Drug Handling Guide and Cleanroom Glove Selection Guide.
Approved catalog examples
Select consumables by task, chemical compatibility and your pharmacy SOP.
The links below are verified SOScleanroom product pages, not automatic endorsements for pharmaceutical compounding or a claim of USP certification. Confirm the current supplier data sheet, availability, package quantity, lot documentation, permitted chemical use and your approved procurement specification.
Routine worktop wipe
/product/wipers/texwipe-tx1009-alphawipe-9-x-9-polyester-cleanroom-wiper/
General absorbent wipe
/product/wipers/texwipe-tx609-technicloth-9-x-9-cellulose-and-polyester-cleanroom-wiper/
Pre-wetted solvent wipe
/product/wipers/texwipe-tx8949p-texvantage-9-x-9-polyester-cleanroom-wiper-pre-wetted-70-ipa/
Pre-wetted polyester format
/product/wipers/texwipe-tx1039-alphasat-9-x-9-polyester-cleanroom-wiper-pre-wetted-70-ipa-case-qty/
Detailed equipment cleaning
/product/swabs/texwipe-tx714a-large-alpha-polyester-cleanroom-swab/
Validation sampling
/product/swabs/texwipe-tx714k-large-alpha-sampling-snap-swab-low-toc/
Controlled hand protection
/product/brands/ansell-93-311-nitrilite-cleanroom-nitrile-gloves-class-100-iso-5/
Sterile solution when needed
/product/solutions/texwipe-tx3270-sterile-70-ipa-isopropanol-alcohol-solution-16-oz-bottle-12-case/
A simple selection checklist for purchasing.
- Purpose: Is the item for routine wipe-down, cleaning, sanitizing, direct product contact, sampling, or PPE?
- Sterility: Is a sterile article actually required? Do not spend for or claim sterility without a process reason.
- Compatibility: Check cleaner chemistry, substrate, equipment surface and applicable instructions.
- Performance: Review fibers, extractables, absorbency, dimensions, glove fit and relevant published test data.
- Package and traceability: Choose workable pack sizes, controlled opening, lot identity and approved alternatives.
- Safety and costs: Account for hazardous shipping, flammability, storage, PPE and total cost per completed task.
- Approval: Require review before substituting a different wiper material, cleaner concentration, glove or packaging format.
Browse Cleanroom Wipers, Precision and Sampling Swabs, Cleaning Solutions, Mops and Glove Fit Guidance.
A useful internal audit method
Trace an actual preparation from the approved formula to release.
A vertical trace is effective for training and inspection readiness because it reveals gaps across departments. A clean record should let a reviewer find each item below without searching through unrelated files.
01
Formulation approved
02
Components received
03
Operator authorized
04
Area and equipment ready
05
Batch faithfully documented
06
Release supported
07
Recall traceability works
08
Corrective action closes
The facility’s official SOPs determine what records are required and who approves them. This audit method is a suggested operational framework, not a claim that the chapter requires this exact eight-step checklist.
From theory to practice
Four common compounding situations and the control questions they raise.
Scenario 01
A second formula needs the same bench
Scenario 02
A preservative is added to an aqueous formula
Scenario 03
The balance fails a verification check
Scenario 04
A preferred 70% IPA wipe is unavailable
These are illustrative training scenarios. Specific dispositions, BUD decisions and cleaning protocols belong to qualified pharmacy personnel and the applicable controlled procedures.
Connect the knowledge base
Related SOScleanroom guides for deeper practical education.
Audit checklist
USP <795> Nonsterile Compliance Checklist
Sterile comparison
USP <797> Cleaning Solutions
Hazardous drugs
USP <800> Handling Guide
Chemical/application fit
Match Solutions to Wipers and Swabs
Supplier selection
Cleanroom Product Match
Operator education
Training and How-to Guides
Technical library
Technical Vault — All Resources
Procurement continuity
Sterile Procurement Planning
Frequently asked questions
Direct answers for pharmacists, technicians and technical buyers.
Does USP <795> require an ISO Class 5 cleanroom?
No universal ISO Class 5 requirement applies to all nonsterile compounding. The chapter requires appropriate designated space and controls; certain risks and additional standards may require more specialized facilities.
Is USP <795> the same as USP <797>?
No. <795> governs compounded nonsterile preparations; <797> addresses compounded sterile preparations and different aseptic/environmental requirements.
Does every nonsterile formulation require a Master Formulation Record?
The revised chapter requires an MFR for each unique CNSP formulation and a Compounding Record for each compounded preparation.
How often must personnel competency be re-evaluated?
ASHP’s 2023 chapter comparison identifies initial qualification and re-evaluation at least every 12 months; verify applicable chapter wording and additional local requirements.
When should worktops be cleaned and sanitized?
At the beginning and end of compounding shifts, between preparations with different components, after spills and when contamination is known or suspected. Follow the official chapter and facility procedure.
Are sterile wipers mandatory for routine USP <795> cleaning?
No general requirement makes every routine nonsterile compounding wipe sterile. Select cleaning tools and chemistry for the actual task and the facility’s defined controls.
Can 70% IPA remove all compounded-drug residues?
No. Alcohol is not a universal cleaner, deactivation agent or sporicide. Drug residue and surface compatibility may require different approved cleaning methods.
What is the difference between cleaning and sanitizing?
Cleaning removes soil and residue; sanitizing reduces microbial burden using an appropriate agent and method. Separate cleaning should occur before sanitizing.
What is water activity and why does it matter?
Water activity (a_w) measures water availability in a product, distinct from total water content. It helps categorize CNSPs for default BUD assignment and microbial-growth considerations.
Is every preserved aqueous CNSP stable for 35 days?
No. Thirty-five days is a default upper limit only in the specified absence-of-evidence framework, not a stability guarantee. Shorter dates may be required.
Can I put a 180-day BUD on any capsule or ointment?
No. The preparation must meet the relevant nonaqueous category and remain chemically, physically and microbiologically suitable; shorter dates and other chapter restrictions may apply.
Does a manufacturer expiration date equal a compounded preparation BUD?
No. The manufacturer’s dating applies to its specified item/conditions; the final preparation requires its own BUD rationale based on the final formulation and storage.
Do hazardous-drug compounds need additional precautions?
Yes, if hazardous-drug handling requirements apply. Evaluate USP <800>, occupational safety and exposure-control needs rather than relying solely on <795> sanitation.
Is a cleaner labeled “cleanroom safe” automatically suitable for compounding?
No. Review chemistry, contact time, residue, surface compatibility, safety information and your approved SOP before use.
Do all compounded drugs undergo FDA approval?
No. FDA states that compounded drugs are not FDA-approved; qualifying compounding activities are governed by distinct federal and state requirements.
Can SOSCleanroom certify my facility’s USP compliance?
No. SOSCleanroom supplies candidate consumables and manufacturer product information; facility leadership, quality personnel and regulators determine requirements and compliance.
Primary sources and official context
Authoritative references for chapter scope, implementation and federal requirements.
The following references are included to support editorial transparency. Licensed USP–NF text, applicable state law and current facility-specific requirements take precedence over summaries and educational guides.
| Source | How to use it |
|---|---|
| USP General Chapter <795> official record | Scope, title and official USP–NF chapter pathway. Access to full text may require a subscription. |
| USP Compounding <795> resource portal | Publisher updates and reference pathway. |
| ASHP: Key Changes to USP <795> (2023) | Summary of designated-person, training, hygiene, cleaning, record and BUD revisions. |
| Kentucky Board of Pharmacy <795> Inspection Template | Practical examples of inspection controls and cleaning frequency interpretations. |
| Illinois Nonsterile Compounding Self-Inspection | Current operational checklist and cleaning/sanitizing references for that jurisdiction. |
| FDA: Compounding Questions and Answers | Federal jurisdiction, safety, quality and differences between 503A and 503B. |
| FDA: 503A Bulk Drug Substances | Supplier, monograph, registered establishment and COA requirements for bulk substances. |
| UConn School of Pharmacy: Nonsterile Compounding | Educational synthesis of BUD categories, records and formulation-quality issues. |
Publisher/source review: October 27, 2026. Editions, rules, external URLs, product specifications and local requirements may change.
SOSCLEANROOM | NONSTERILE COMPOUNDING SUPPLY SUPPORT
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Educational scope: This guide summarizes selected USP <795> concepts for professional education and product-selection discussion; it is not a licensed copy of USP–NF, a compounding instruction, a medication stability determination, a facility compliance certificate or legal/clinical advice. Obtain the currently official USP chapter and all applicable federal/state requirements. Only the authorized pharmacy professional and quality organization may determine the appropriate SOP, ingredient selection, preparation BUD, cleaning program, handling controls, suitability of purchased products and release of compounded preparations. SOScleanroom does not compound medications or approve facilities.