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Course: Oncology Nursing

Topic: Safe Handling of Hazardous Drugs

The Nurses International Community

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Module Goals

Learners will be able to:

Identify hazardous drugs related to cancer treatment.
Describe the risk of exposure to hazardous drugs and its consequences.
Describe use of personal protective equipment (PPE), spill cleanup and waste disposal of hazardous drugs in cancer treatment.

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Cytotoxic Drugs/ Hazardous Drugs

Government of South Australia (2015).
PAHO (2013).

Cytotoxic drugs¹:

Highly toxic to cells mainly through their action on cell reproduction.
Carcinogenic, mutagenic or teratogenic.
Subsets of antineoplastic drugs.

Hazardous drugs (HD)^1,2:

Agents that, due to its inherent toxicity, presents a danger to health care personnel.
May be carcinogenic, teratogenic, genotoxic.
Developmental, reproductive or organ toxicity regardless of dose.
Include antiviral and hormonal, bioengineered drugs, and others.

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Who Is At Risk?

Government of South Australia (2015)

Personnel at risk if involved in :

preparing drugs
administering drugs
cleaning up spills
transporting drugs
storing drugs
handling cytotoxic waste
transporting and disposing waste

Exposure occur through:

skin contact/absorption
inhalation of aerosols and drug particles
ingestion
sharps injuries

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Critical Thinking Question:

Why are drugs used for targeted therapy in cancer treatment considered hazardous drugs?

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Safe Handling Of Hazardous Drugs

Transportation
Storage
Compounding
Administration to the patient
Cleanup of spills
Cleaning/decontamination of equipments/work surfaces
Managing Waste
Medical surveillance of hazardous drug handlers
Training of personnel who handle hazardous drugs

PAHO (2013)

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Transportation Of Hazardous Drugs

Government of South Australia (2015)
PAHO (2013)

When transporting from manufacturer to hospital/clinics, HD containers must be¹

hard walled, robust and capable of withstanding shock equivalent to one meter drop onto a concrete surface
Securely closed and sealed

Employee receiving the HD drugs must²

Wear gloves while inspecting packages for its intactness
Appropriate PPEs to be worn when handling damaged package

Double gloves, gown, eye protection, and respirator

Biohazard Sign

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Transportation Of Hazardous Drugs

When transporting from pharmacy to wards/units for in-house use

Sealed, leak-proof container
Outer package heat- sealed where possible
Container protect from light and breakage
Contain leakage if breakage occurs
Childproof packaging
Tablet containers label ‘do not cut or crush’
Containers appropriately labelled for specified use
-e.g intrathecal, oral or topical
Packaging labelled ‘Cytotoxic- Handle with care’ label

Government of South Australia (2015)

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Storage of Hazardous Drugs (HD)

Storage area must have:

Good ventilation
Negative air pressure with minimum 12 air changes per hour to reduce drug residue in breathable air

Wear one or two pairs of gloves approved for use with HD
Each HD vial or ampoule must be wiped with appropriate solution before use

Do not spray HD container directly to prevent transfer to air/surfaces
Wiper should be contained and discarded after use appropriately

PAHO (2013)

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Compounding Of Hazardous Drugs

Strict aseptic technique used to keep doses sterile.
HD is contained in HD container/syringe/IV bag.
Final doses of HD must be in ready-to-administer form when transporting to the patient.

Patient-specific labeling and label of ‘HD’.

Doses in IV bags must have IV tubing connected with line primed with non-HD containing solution.
Doses in syringe must be clear of air, must not require further manipulation.

PAHO (2013)

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Administration Of Hazardous Drugs

PAHO (2013)

Always follow instructions from manufacturers/pharmacy for administration

Wash hands before and after HD handling
Put on PPE before removing HD from the delivery container

Wear two pairs of chemotherapy tested gloves.
Wear chemotherapy gown.
Wear a face shield if there is chance of HD splashing.
Wear a respirator if HD aerosols may be present .

Inspect the delivery container and its contents before handling.

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Administration Of Hazardous Drugs

Use of close system drug administration devices where possible.
Avoid priming HDs into gauze pads, sinks, or trash containers.
All manipulations done below eye level.
Used administration sets and syringes discarded intact into designated HD waste containers.
PPE removed in such a way as to prevent contamination of hands and clothing.
Dispose used PPE, do not hang up and reuse gowns.

PAHO (2013)

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Administration Of Hazardous Drugs

Government of South Australia (2015)

During HD drug administration:

Do not recap needles
Do not use cut down intravenous infusion sets or contaminated needles
Do not expel air from a syringe (it contaminates the air)
Do not expel fluid from a syringe (it contaminates the area)

Spill kit must be available nearby!

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Administration Of HD: Intravesical Route

Additional risk control measure include:

Limit leakage and explosive aerosol spray of unmetabolized HD:

Patient must limit fluid intake for 4 hours prior to administration.
Patient must void prior catheterization..
Catheter removed as soon as possible after instillation.

Limit environmental contamination:

6 hours post-treatment patient must sit for every urination.
double flushing toilet prior to decontamination with sodium hypochlorite solution.

Government of South Australia (2015)

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Administration Of HD: Oral Route

Government of South Australia (2015)

Additional risk control measure include:

Apply non-touch technique when transferring tablet/capsules from container into disposable medication cup.
Do not crush or break tablets/capsules outside of pharmacy’ cytotoxic drug preparation area.

contact pharmacy to compound a cytotoxic drug mixture.

Isolate and discard damaged tablets/capsules as cytotoxic waste and notify pharmacy.

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Spill Management

Government of South Australia (2015)

Spill may happen from

Preparation, storage , transport of packaged drugs.
Administration or disposal of drugs.
Transport of a patient receiving drug therapy.
Contaminated body waste/substance.

Spill kits must be readily available:

During transport/transfer of HD
Storage area
Pharmacy site where HD are compounded
Medication administration area
Waste management area

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Spill Kit Contents

PAHO (2013)
Government of Southern Australia (2015)

Two pairs of disposable chemical-protective gloves.
Low permeability, disposable protective garment (gown or coverall, shoe covers).
Face shield and Respirator (N95 or better).
Absorbent, plastic-backed sheets or spill pads.
Disposable towels.
Two sealable, thick plastic waste disposal bags.
A disposable scoop for collecting glass fragments.
A puncture-resistant container.
Suitable cleaning/decontaminating agent may also be included².
Sign saying “Caution Hazardous Drug Spill”.

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Spill Containment

People in immediate vicinity of a spill should be alerted to the incident.
Area must be isolated with appropriate signs.
HD spill cleanup must be allocated to person who is

Trained in handling of risks associated with cytotoxic drugs
Not contaminated with cytotoxic drugs

Incident of spill must be reported as soon as possible to concerned authority.

Government of South Australia (2015)

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Cleaning/Decontamination of Equipment and Work Surface

Decontamination may be defined as deactivating.
No single process has been found to deactivate all currently available HDs.
If available PEC such BSC or CACI should be decontaminated per manufacturer recommendations.
Safety data sheets for many HDs recommend sodium hypochlorite solution as an appropriate agent.

PAHO (2013)

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Cleaning/Decontamination of Equipment and Work Surface

Decontamination and cleaning steps:

1st: Wipe contaminated surfaces with 2% sodium hypochlorite solution with detergent, and rinse.

2nd: Wipe on and off with neutralizing solution of 1% sodium thiosulfate.

3rd: Rinse with water solution.

4th: Rinse with alcohol.

Surface contact for each solution should be at least 30 seconds.
This cleaning technique can be used in any surface that will not be harmed by bleach solution.

PAHO (2013)

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Waste Disposal of HD

HD waste are waste that is contaminated by hazardous/Cytotoxic drugs.
HD waste disposal:

HD waste disposal containers must be segregated from other waste disposal containers and labeled as such
HD disposal containers must be available at every site that has possibility of HD waste

e.g drug administration unit, pharmacy, storage etc.

HD bins/containers must be leak proof, hard-walled, and sealed prior to the collection by waste collectors

Government of South Australia (2013)

Contact info: info@nursesinternational.org

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Waste Disposal of HD

All HD waste should be placed in HD waste disposal bags/containers
HD waste storage areas should be:

Appropriately dedicated, sign-posted, secure,
Well-lit and ventilated
Away from drains and other sensitive areas

Appropriate PPE must be worn while handling HD waste.
Incineration at 1100°C is the only approved technology for treating cytotoxic waste.

Government of South Australia (2013)

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What would the nurse do?

What is the nurse’s role and responsibilities in the safe handling of the hazardous drugs? (Select all that apply)

The nurse ensures that the hazardous drugs are stored, mixed, administered, and disposed of according to safety protocols.
The nurse wears a plastic apron and cotton gloves when administering the medications.
The nurse serves as a peer and facility resource and a patient advocate in terms of ensuring safety to personnel and patients.
The nurse should make sure a spill kit is readily available.

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Nurse’s Role

Stay updated with current cytotoxic and hazardous drugs list.
Implement national/local/agency policies and procedures on safe handling recommendations, use of PPE and the process of spill cleanup in to practice.
Practice agency’s standard of procedure/protocols on administration of cytotoxic/hazardous drugs.
Protect yourself, your colleagues, and patients by being aware of the risks and areas for improvement in your setting.
Document and report safety concerns to respective authority.

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Reference:

Government of South Australia (2015). Cytotoxic Drugs and Related Waste: A Risk Management Guide for South Australian Health Services. Accessed from: https://www.sahealth.sa.gov.au/wps/wcm/connect/public+content/sa+health+internet/clinical+resources/clinical+programs+and+practice+guidelines/medicines+and+drugs/hazardous+drugs

Safe Handling of Hazardous Chemotherapy Drugs in Limited-Resource Settings. Washington, DC : PAHO, 2013. Accessed from: https://www.paho.org/hq/dmdocuments/2014/safe-handling-chemotherapy-drugs.pdf

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