Prevention Guide - Safe Handling of Hazardous Drugs - Irsst

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2. RISKS RELATED TO THE USE OF HAZARDOUS DRUGS 2.2.2 Hazardous Drug Entry Routes into the Body Hazardous drugs may enter the body through skin absorption, ingestion, accidental injection (e.g. needlesticks) or inhalation. Skin absorption is the main known penetration route and occurs through direct contact with contaminated surfaces or objects. For example, contact with the contaminated exteriors of drug vial is one source of contamination. Contaminated work surfaces, the excreta and bedding of patients treated with antineoplastic drugs, drug leaks, etc. are other sources of exposure. Most often, the contamination is spread by the hands; this is why the wearing of gloves and handwashing are such important preventive measures. Ingestion can occur through eating contaminated food or by putting contaminated fingers or objects (in particular, pencils) in the mouth. The significance of inhalation as an exposure route has not been clearly established. A number of studies report low levels of dust or particles in the air. However, these studies do not usually check for the presence of vapours, despite the fact that it has recently been determined that some drugs are volatile (Turci, 2003, Kiffmeyer, 2002, Opiolka, 2000, Connor, 2000). Contamination can occur through the inhalation of drug vapours. In view of the fact that some hazardous drugs are capable of generating vapours, appropriate preventive measures must be taken (for example, a biological safety cabinet which does not recirculate the air in the room). The drug particles can turn into vapour in a few seconds or minutes, depending on the product. A study by Kiffmeyer (2002) demonstrated that the six drugs studied (carmustine, cisplatin, cyclophosphamide, etoposide, fluorouracil, fosfomycin) are capable of evaporating. Measurements of cyclophosphamide in gaseous form revealed the presence of the drug in 7 out of 20 samples. However, as the drug monographs do not generally include data regarding the volatility of hazardous drugs, it is not possible to compile a list of these. 2.2.3 Potential Sources of Exposure Exposure can occur at any step in the medication circuit, i.e., creation of aerosols during the preparation or administration of hazardous drugs, leaks or spills during transport or handling, contact with contaminated surfaces or objects, contact with wastes or excreta; etc. Table 1 summarizes the target workers and primary potential sources of contamination at each step of the circuit. In addition to those individuals involved in the main steps of the medication circuit, we should not forget the biomedical engineering workers, who may have to become involved to maintain or repair the pumps and equipment used to administer the drugs. In view of the local variability of practices and potential sources of exposure, it is difficult to establish a single risk hierarchy based on potential sources of exposure. While the majority of hazardous drugs are stored, prepared and administered in a limited number of locations (i.e., oncology pharmacy, care units, outpatient clinics, etc.), they can also be administered elsewhere in the institution (e.g. operating rooms). The guide does not suggest recommendations according to location type. It is up to the Occupational Health and Safety Program Manager to apply the general recommendations to specific situations (e.g. using an appropriate transport container between the pharmacy and the operating room, as well as making appropriate operating room waste receptacles available in the rooms where hazardous drugs are administered, etc.). 2-6 ASSTSAS PREVENTION GUIDE – SAFE HANDLING OF HAZARDOUS DRUGS
2. RISKS RELATED TO THE USE OF HAZARDOUS DRUGS Table 1. Medication Circuit Steps, Exposed Workers and Main Sources of Exposure Medication Circuit Steps Potentially Exposed Workers Potential Sources of Exposure to Hazardous Drugs Receiving and Transport (Chapter 5) Unpacking and Storage (Chapter 6) Drug Preparation (Chapter 8) Receiving or transport clerks (e.g. stock-keeper, storeroom clerk) Hygiene and sanitation workers Pharmacy Department workers (e.g. pharmacist, clerk, pharmacy technician) Pharmacy Department workers (e.g. pharmacist, clerk, pharmacy technician) Hygiene and sanitation workers Pharmacy Department workers (e.g. pharmacist, clerk, pharmacy technician) Hygiene and sanitation workers Maintenance workers (e.g. biomedical engineering workers or preparation cabinet certifier) Damaged or contaminated packages or delivery containers Breakage of a container due to a fall or other cause Damaged or contaminated packages or delivery containers Contamination of outside surfaces of drug vials from the manufacturer The handling of hazardous drugs, particularly during their preparation (i.e., reconstitution, dilution, bagging or filling of syringes, etc.) may be a major source of work environment contamination, even in the general areas of the pharmacy. The lack or ineffectiveness of measures to contain these sources (e.g. air recirculation hood, diffusion of contaminants outside the sterile preparation room) may contribute to worker exposure. Direct contact with contaminated vials from the manufacturer. Direct contact with hazardous drugs during handling (e.g. when counting solid oral forms, contact when adding diluent, when agitating the drug container, when transferring the solution into another container, such as a syringe, bag or other administration device). Direct contact with the bins or trays used to transport hazardous drug preparations (e.g. syringes, bags containing hazardous drugs) during their packaging or transfer to the care units or outpatient clinics. Contact with contaminated equipment (e.g. the plunger of syringes containing drugs, the pumps during their maintenance or repair or the HEPA filters during their replacement). Exposure to hazardous drug particles or vapours in the immediate vicinity of the preparation cabinet due to leaks through the front opening. Such leaks may be caused by rapid arm movements or obstruction of the front filter grille of the cabinet. PREVENTION GUIDE – SAFE HANDLING OF HAZARDOUS DRUGS ASSTSAS 2-7
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8. DRUG PREPARATION or “Caution
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8. DRUG PREPARATION 8.3.9 Preparing
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8. DRUG PREPARATION Wearing both
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9. TRANSPORT AND STORAGE FOLLOWING
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10. ADMINISTRATION OF DRUGS Adminis
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10. ADMINISTRATION OF DRUGS Nurses
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10. ADMINISTRATION OF DRUGS Primary
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10. ADMINISTRATION OF DRUGS Establi
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10. ADMINISTRATION OF DRUGS if a o
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10. ADMINISTRATION OF DRUGS 10.3.10
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10. ADMINISTRATION OF DRUGS 10.3.13
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10. ADMINISTRATION OF DRUGS contain
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11. PATIENT CARE 11 PATIENT CARE 11
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11. PATIENT CARE arrive (see 13.3.1
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11. PATIENT CARE Table 8. Hazardous
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12. MANAGEMENT OF WASTE, ACCIDENTAL
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13. HYGIENE AND SANITATION 13.2 Exp
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14. LAUNDRY 14 LAUNDRY 14.1 Issues
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15. MEDICAL, BIOLOGICAL AND ENVIRON
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15. MEDICAL, BIOLOGICAL AND ENVIRON
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16. REFERENCES 16 REFERENCES AHQ [1
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16. REFERENCES Nygren O., Lundgren
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APPENDIX 1 - GLOSSARY APPENDIX 1- G
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APPENDIX 1 - GLOSSARY TERMS DEFINIT
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APPENDIX 1 - GLOSSARY TERMS DEFINIT
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APPENDIX 2 - LIST OF HAZARDOUS DRUG
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APPENDIX 3 - SURVEY REGARDING PRACT
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APPENDIX 4 - HAZARDOUS SPILL MANAGE
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APPENDIX 4 - HAZARDOUS SPILL MANAGE
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5. MEASUREMENT OF WORK SURFACE CONT
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