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Mind the Gaps: Assessing Your Institution’s Compliance with USP Chapter <797>

Health systems have worked diligently to ensure that they are in compliance with the revised USP Chapter <797> requirements. This educational activity will summarize key revisions to the revised chapter as well as review how to assess facility and personnel, policy and procedure development and review, beyond-use dating, environmental monitoring, and accreditation gaps. Best practices for training and monitoring personnel will also be presented.

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Target Audience

This activity was planned to meet the educational needs of pharmacists, pharmacy technicians, and medication safety officers practicing in hospitals and health system. 

Learning Objectives

  1. Summarize key revisions to USP Chapter <797>, including the types and frequency of baseline and ongoing testing.

  2. Assess facility, personnel, policy and procedure development and review, environmental monitoring, and accreditations gaps.

  3. Apply best practices for training and evaluating personnel, particularly the designated person(s).


  • Introduction and Announcements
  • Presentation
  • Questions, Answers, and Discussion


Patricia C. Kienle, RPh, MPA, BCSCP, FASHP, Activity Chair, Director, Accreditation and Medication Safety, Cardinal Health

Glen J. Gard, CPhT-Adv, CSPT, FNHIA, National Director, Sterile Compounding & Pharmacy Compliance, Option Care Health

Abby Roth, CMQ/OE, Microbiologist, Pure Microbiology

CE Accreditation

The American Society of Health-System Pharmacists is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education with Commendation.


ACPE Activity Number: 0204-0000-24-402-H07-P/T

Content Release Date: May 1, 2024
Expiration Date: May 21, 2025
Activity Type: Application-based
CE Credits: 1.5 contact hours (0.15 CEUs)
Activity Fee: Free

To receive CE credit, complete the steps below within 60 days of completing the activity.

  1. View the entire presentation and answer all polling questions.
  2. Click "Complete Activity" on last slide then complete the evaluation to claim credit.
  3. Verify credits were successfully transferred to CPE Monitor before the ACPE 60-day deadline by checking your NABP eProfile account.

This activity is provided by ASHPSupported by an educational grant from Pfizer Inc.


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