Hazardous Drugs: Handling in Health Care Settings

Health care workers who handle hazardous drugs (HDs) are exposed to harmful chemicals that can cause serious health risks (Cowman & Daly, 2017; Randolph, 2012). Careful handling of HDs is required to minimize adverse health effects of exposure and reduce contamination of the workplace (Oncology Nursing Society, 2018). HDs include those used for cancer therapy (carcinogen, genotoxin, teratogen, reproductive toxin), some antiviral drugs, hormone agents, bioengineered drugs, carcinogens, and new drugs that mimic HDs in structure or toxicity (Kienie, 2016; National Institute for Occupational Safety and Health [NIOSH], 2018).

The U.S. Pharmacopeial (USP) Convention (2017) released General Chapter <800>, “Hazardous Drugs—Handling in Healthcare Settings,” in February 2016 with an enforcement date of December 1, 2019. It provides guidance on risk assessment; education/training; facility engineering controls; safe work practices; proper use of appropriate personal protective equipment (PPE); receiving, labeling, packaging, transport, and disposal of HDs; and medical surveillance. Occupational and environmental health nurses may be involved in some of these areas and should collaborate with colleagues in pharmacy, nursing, and environmental health. A gap analysis may be needed to determine what changes are required by USP <800>.

A key component of USP <800> is the identification of HDs in the workplace. Each facility must create and maintain a list of HDs administered in that facility and review the list annually and whenever a new agent or dosage form is added. The NIOSH (2016) list of antineoplastic and other HDs in health care settings can help guide HD identification.

Exposure to HDs can occur during dispensing, compounding, and administering; patient care activities; and spill and transport situations. Aerosols may be generating during HD administration by injection, irrigation, oral, inhalation, or topical application; performing certain specialized procedures; and priming an intravenous administration set.

USP <800> and NIOSH specify requirements for PPE. Double gloving is now required for HD administration and gloves should be designated for chemotherapy (Eisenberg, 2017; Wiley, 2017). Gowns are required for specific HD activities such as administration, disconnection, and disposal of HDs and spill cleanup. A standard operating procedure (SOP) must describe the appropriate PPE (gloves, gown, head/hair/shoe/sleeve covers, eye and face protection, and respiratory protection) to be used based on the occupational safety plan/assessment of risk.

Occupational and environmental health nurses may be involved with training and documentation of individuals who handle HDs. Training must occur before the employee independently handles or administers HDs. The competency of each individual must be reassessed at least annually, when a new HD or new equipment is used, or if a change in process has occurred. Training topics include overview of HDs and their risk, review of the procedures related to handling HDs, proper use of PPE, proper use of equipment and devices, spill management, and response to known or suspected HD exposure.

Personnel who handle HDs should be in a medical surveillance program which includes a baseline physical assessment with a medical history, reproductive history, prior exposure to HDs, estimated quantity of HD handled per week, number of hours spent handling HDs, complete blood count (CBC), and biological monitoring such as urine testing. After a known exposure, the employee should be monitored for any changes in health.

Occupational and environmental health nurses can play a key role in the implementation of the USP <800> guidelines to protect the health and safety of all workers who handle HDs.