The Joint Commission requires that the hospital assesses competency of staff who conduct sterile medication compounding of nonhazardous and hazardous medications in accordance with state and federal law and regulation and hospital policies (MM05.01.07, EP3). Anesthesiologists regularly perform sterile compounding. Other physicians may perform very limited sterile compounding. During the TJC survey at SMH, SMH was cited for not having sterile competency training documented for an anesthesiologist...