Available Until 5/21/2025

Elevating Compliance: Navigating USP <797> with Technology and Standardization

ACPE Activity Number:  0204-0000-24-403-H07-P/T
Content Release Date: May 21, 2024
Expiration Date: May 21, 2025
Activity Type: Application-based   
CE Credits: 1.0 contact hour (0.10 CEUs)
Activity Fee: Free

Activity Overview

Health systems have worked diligently to ensure that they are in compliance with the revised USP Chapter <797> requirements. This educational activity will demonstrate how health systems of any size can perform a gap analysis of its facility, personnel, policy and procedure development and review, environmental monitoring, and accreditation. Recognizing the important safety features of technologies and standardization of IV compounding, the education will also address how they might be implemented in small, medium, and large institutions.

*Please note, this activity was presented live as a live webinar on 4/09/24. You can only claim credit once for this activity; live or home study.

Frontline Conversations:Coming this Summer! 

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.

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

At the conclusion of this activity, participants should be able to:

  • Perform a gap analysis that includes facility, personnel, policy and procedure development and review, environmental monitoring, and accreditation gaps.
  • Identify opportunities to implement technologies and standardization that improve safety of IV compounding in small, medium, and large institutions.

Schedule of Activities

  • Introduction and Announcements 

  • Presentation  

  • Questions, Answers, and Discussion 

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

Patricia Kienle is Director of Accreditation and Medication Safety for Cardinal Health. She received her pharmacy degree from Philadelphia College of Pharmacy and Science and a Master in Public Administration degree from Marywood University in Scranton, Pennsylvania. She is author of The Chapter <795> Answer Book, The Chapter <797> Answer Book, and The Chapter <800> Answer Book and co-author of Meeting Accreditation Standards: A Pharmacy Preparation Guide. With over 600 invited presentations and 100 publications, she has special interests in medication safety, compounding sterile preparations, accreditation, and regulatory issues.


Ashley M. Duty, PharmD, MS, BCSCP, FASHP
Director of Inpatient Pharmacy Operations
Nationwide Children's Hospital
Columbus, Ohio

Dr. Duty earned her Doctor of Pharmacy from the Raabe College of Pharmacy at Ohio Northern University and a Master’s of Science in Health-System Pharmacy Administration from Northeast Ohio Medical University. She completed a PGY1/2 Health-System Pharmacy Administration residency at the Cleveland Clinic. Ashley is currently Director of Pharmacy Operations at Nationwide Children’s Hospital in Columbus, Ohio. Prior to this, Ashley served as a pharmacy manager at Children’s Mercy Kansas City. In 2019, Ashley became a Board Certified Sterile Compounding Pharmacist. Ashley’s interests include sterile compounding operations, medication safety, and policy work.

Kevin N. Hansen, PharmD, MS, BCSCP
Director, 503B Program
Premier Inc.
Charlotte, North Carolina


Dr. Hansen is Director of the 503B Program at Premier Inc., based in Charlotte, North Carolina. He earned his Doctor of Pharmacy degree from LECOM, completed a PGY1/PGY2/MS health-system pharmacy administration and leadership residency program at the University of North Carolina Medical Center, and is a board-certified sterile compounding pharmacist.

In accordance with our accreditor’s Standards of Integrity and Independence in Accredited Continuing Education, ASHP requires that all individuals in control of content disclose all financial relationships with ineligible companies. An individual has a relevant financial relationship if they have had a financial relationship with an ineligible company in any dollar amount in the past 24 months and the educational content that the individual controls is related to the business lines or products of the ineligible company. 

An ineligible company is any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients. The presence or absence of relevant financial relationships will be disclosed to the activity audience. The following persons in control of this activity’s content have relevant financial relationships:

  • Patricia C. Kienle: BD – Speaker’s Bureau
  • Kevin N. Hansen: Omnicell – Speaker’s bureau, Advisory Board; Baxter – Speaker’s bureau

All other persons in control of content do not have any relevant financial relationships with an ineligible company. As defined by the Standards of Integrity and Independence in Accredited Continuing Education definition of ineligible company. All relevant financial relationships have been mitigated prior to the CE activity.

Claim CE Within 60 Days

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.

Per ACPE requirements, CPE credit must be claimed within 60 days of being earned – no exceptions! To verify that you have completed the required steps and to ensure your credits have been reported to CPE Monitor, we encourage you to check your NABP eProfile account to validate your credits were transferred successfully before the ACPE 60-day deadline. After the 60 day deadline, ASHP will no longer be able to award credit for this activity.

Provided by ASHP

Supported by an educational grant from Pfizer Inc.