Safe Handling of Hazardous Drugs
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Best Practices for the<br />
<strong>Safe</strong> <strong>Handling</strong><br />
<strong>of</strong> <strong>Hazardous</strong> <strong>Drugs</strong>
About Work<strong>Safe</strong>BC<br />
At Work<strong>Safe</strong>BC, we’re dedicated to promoting safe and healthy workplaces across B.C. We<br />
partner with workers and employers to save lives and prevent injury, disease, and disability.<br />
When work-related injuries or diseases occur, we provide compensation and support injured<br />
workers in their recovery, rehabilitation, and safe return to work. We also provide no-fault<br />
insurance and work diligently to sustain our workers’ compensation system for today and future<br />
generations. We’re honoured to serve the workers and employers in our province.<br />
Work<strong>Safe</strong>BC Prevention Information Line<br />
The Work<strong>Safe</strong>BC Prevention Information Line can answer your questions about workplace<br />
health and safety, worker and employer responsibilities, and reporting a workplace incident.<br />
The Prevention Information Line accepts anonymous calls.<br />
Phone 604.276.3100 in the Lower Mainland, or call 1.888.621.7233 (621.SAFE) toll-free in<br />
Canada.<br />
To report after-hours and weekend incidents and emergencies, call 604.273.7711 in the<br />
Lower Mainland, or call 1.866.922.4357 (WCB.HELP) toll-free in British Columbia.
Best Practices for the<br />
<strong>Safe</strong> <strong>Handling</strong><br />
<strong>of</strong> <strong>Hazardous</strong> <strong>Drugs</strong>
Work<strong>Safe</strong>BC publications<br />
Many publications are available on the Work<strong>Safe</strong>BC website. The Occupational Health and<br />
<strong>Safe</strong>ty Regulation and associated policies and guidelines, as well as excerpts and summaries <strong>of</strong><br />
the Workers Compensation Act, are also available on worksafebc.com.<br />
Some publications are also available for purchase in print:<br />
Phone: 604.232.9704<br />
Toll-free phone: 1.866.319.9704<br />
Fax: 604.232.9703<br />
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Online ordering: worksafebc.com and click on Publications; follow the links for ordering<br />
ISBN 978-0-7726-6927-8<br />
©2015 Workers’ Compensation Board <strong>of</strong> British Columbia. All rights reserved. The Workers’<br />
Compensation Board <strong>of</strong> B.C. encourages the copying, reproduction, and distribution <strong>of</strong> this<br />
document to promote health and safety in the workplace, provided that the Workers’<br />
Compensation Board <strong>of</strong> B.C. is acknowledged. However, no part <strong>of</strong> this publication may be<br />
copied, reproduced, or distributed for pr<strong>of</strong>it or other commercial enterprise, nor may any part<br />
be incorporated into any other publication, without written permission <strong>of</strong> the Workers’<br />
Compensation Board <strong>of</strong> B.C.
Acknowledgments<br />
Work<strong>Safe</strong>BC thanks the many organizations who generously donated their time and knowledge to<br />
reviewing this edition <strong>of</strong> Best Practices for the <strong>Safe</strong> <strong>Handling</strong> <strong>of</strong> <strong>Hazardous</strong> <strong>Drugs</strong>, including:<br />
••<br />
BC Provincial <strong>Hazardous</strong> <strong>Drugs</strong> Working Group<br />
••<br />
BC Provincial <strong>Hazardous</strong> Drug List Working Group<br />
••<br />
College <strong>of</strong> Pharmacists <strong>of</strong> BC<br />
••<br />
University <strong>of</strong> British Columbia<br />
••<br />
BC Nurses’ Union<br />
••<br />
College <strong>of</strong> Veterinarians <strong>of</strong> BC<br />
••<br />
Health Sciences Association <strong>of</strong> BC
Contents<br />
About this book. ................................ 1<br />
Part 1: <strong>Hazardous</strong> drugs in the workplace ............. 3<br />
1. What are hazardous drugs? ...........................5<br />
2. Who is at risk <strong>of</strong> exposure? ...........................6<br />
3. Why are workers at risk? .............................7<br />
4. Routes <strong>of</strong> occupational exposure .......................8<br />
5. Creating an exposure control plan .....................10<br />
Part 2: Performing a risk assessment for hazardous drugs. ..11<br />
6. What is a risk assessment? ..........................13<br />
7. Identifying hazardous drugs ..........................15<br />
8. Assessing risk .....................................17<br />
8.1 Tools for assessing risk ..........................18<br />
9. Developing and implementing control measures .........20<br />
10. Written safe work procedures .......................23<br />
11. Information and communication .....................24<br />
11.1 Education and training ..........................25<br />
11.2 Written records ...............................25<br />
Part 3: Task-specific guidelines for reducing exposure<br />
to hazardous drugs. ............................. 27<br />
12. Drug shipping ....................................29<br />
13. Drug receiving and storage ..........................30<br />
13.1 Work area design .............................30<br />
13.2 Equipment ...................................31<br />
13.3 Guidelines for safe work practice .................31<br />
13.4 Personal protective equipment (PPE) ..............31<br />
14. Drug transport ....................................32<br />
14.1 Equipment ...................................32<br />
14.2 Guidelines for safe work practice .................32<br />
14.3 Personal protective equipment (PPE) ..............32<br />
15. Drug preparation ..................................33<br />
15.1 Work area design .............................33<br />
15.2 Equipment ...................................34<br />
15.3 Guidelines for safe work practice .................36<br />
15.4 Cleaning .....................................36<br />
15.5 Personal protective equipment (PPE) ..............37<br />
Best Practices for the <strong>Safe</strong> <strong>Handling</strong> <strong>of</strong> <strong>Hazardous</strong> <strong>Drugs</strong><br />
v
16. Drug administration ...............................38<br />
16.1 Work area design .............................38<br />
16.2 Drug administration equipment ..................38<br />
16.3 Guidelines for safe work practice .................39<br />
16.4 Cleaning .....................................39<br />
16.5 Considerations for home care ...................40<br />
16.6 Personal protective equipment (PPE) ..............41<br />
17. Veterinary practice. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42<br />
17.1 Work area design ..............................42<br />
17.2 Equipment ...................................43<br />
17.3 Guidelines for safe work practice .................43<br />
17.4 Cleaning .....................................43<br />
17.5 Personal protective equipment (PPE) ..............44<br />
18. Patient care ......................................45<br />
18.1 Work area design .............................45<br />
18.2 Equipment ...................................45<br />
18.3 Guidelines for <strong>Safe</strong> Work Practice ................46<br />
18.4 Cleaning .....................................46<br />
18.5 Personal protective equipment (PPE) ..............46<br />
19. Cleaning .........................................47<br />
19.1 Guidelines for safe work practice .................47<br />
19.2 Personal protective equipment (PPE) ..............47<br />
20. Waste disposal ...................................48<br />
20.1 Work area design .............................48<br />
20.2 Equipment ...................................49<br />
20.3 Guidelines for safe work practice ................49<br />
20.4 Personal protective equipment (PPE) .............50<br />
21. Spill response ....................................51<br />
21.1 Guidelines for safe work practice .................51<br />
21.2 Personal protective equipment (PPE)..............51<br />
Appendices ................................... 53<br />
Appendix 1: References and resources ...................55<br />
Appendix 2: Glossary .................................60<br />
Appendix 3: Monitoring the workplace environment ........63<br />
Appendix 4: Personal protective equipment (PPE) ..........65<br />
Appendix 5: Biological safety cabinets (BSCs)..............68<br />
Appendix 6: Selection <strong>of</strong> medical equipment ..............70<br />
Appendix 7: Cleaning agents ...........................71<br />
Appendix 8: Spill kit checklist ..........................73<br />
vi<br />
Best Practices for the <strong>Safe</strong> <strong>Handling</strong> <strong>of</strong> <strong>Hazardous</strong> <strong>Drugs</strong>
About this book<br />
This book deals with the health and safety <strong>of</strong> workers who handle<br />
hazardous drugs. It is meant to be a starting point and a reference<br />
guide <strong>of</strong> best practices to minimize worker exposure to hazardous<br />
drugs in the workplace. This book has three parts:<br />
••<br />
Part 1 gives an overview <strong>of</strong> current knowledge on hazardous drugs<br />
••<br />
Part 2 describes how to perform a risk assessment<br />
••<br />
Part 3 gives examples <strong>of</strong> best practices for each stage <strong>of</strong><br />
handling hazardous drugs<br />
The book also includes eight appendices:<br />
••<br />
Appendix 1: References and resources<br />
••<br />
Appendix 2: Glossary<br />
••<br />
Appendix 3: Monitoring the workplace environment<br />
••<br />
Appendix 4: Personal protective equipment (PPE)<br />
••<br />
Appendix 5: Biological safety cabinets (BSCs)<br />
••<br />
Appendix 6: Selection <strong>of</strong> medical equipment<br />
••<br />
Appendix 7: Cleaning agents<br />
••<br />
Appendix 8: Spill kit checklist<br />
Who this book is intended for<br />
This book is intended primarily for the health care industry in B.C.,<br />
including those engaged in community or home-based care.<br />
However, Part 3 also provides guidelines for ancillary services,<br />
such as transportation and cleaning, and for veterinary practices.<br />
See Chapter 2: “Who is at risk <strong>of</strong> exposure?” for a list <strong>of</strong> occupations<br />
in which workers are at potential risk <strong>of</strong> exposure to hazardous drugs.<br />
Terminology<br />
Appendix 2 contains a glossary <strong>of</strong> terms frequently used when<br />
handling hazardous drugs. When these terms appear in the text <strong>of</strong><br />
this book, they will be indicated with bold type. If you place your<br />
cursor over the bold text, a pop-up box will appear with the<br />
definition <strong>of</strong> the term.<br />
Best Practices for the <strong>Safe</strong> <strong>Handling</strong> <strong>of</strong> <strong>Hazardous</strong> <strong>Drugs</strong> 1
Legal considerations<br />
While the information in this book is meant to help you meet the<br />
requirements specified in the Occupational Health and <strong>Safe</strong>ty<br />
Regulation (the Regulation), it does not replace it. You will need to<br />
refer to the Regulation to determine the exact requirements that<br />
apply to your particular workplace.<br />
In Canada, drug products fall under the jurisdiction <strong>of</strong> the<br />
Food and <strong>Drugs</strong> Act and are exempt from WHMIS requirements.<br />
However, information requirements under section 5.2 <strong>of</strong> the<br />
Regulation still apply. Chapter 10 provides more information on<br />
how to comply with the Regulation.<br />
Best practices: hazardous and cytotoxic drugs<br />
This book contains recommended best practices that apply when<br />
handling all hazardous drugs. We use the term hazardous drugs to<br />
indicate that occupational exposure should be controlled in the<br />
workplace for all drugs that meet the specified criteria. Employers<br />
should perform a risk assessment before adopting any <strong>of</strong> the<br />
recommendations in this book.<br />
While recommended practice is to reduce worker exposure to any<br />
hazardous drug, exposure to cytotoxic drugs, a subset <strong>of</strong> hazardous<br />
drugs, is specifically regulated by Part 6 <strong>of</strong> the Regulation.<br />
Cytotoxic drugs are defined in section 6.42 <strong>of</strong> the Regulation as<br />
drugs that “... possess a specific destructive action on certain cells<br />
or that may be genotoxic, oncogenic, mutagenic, teratogenic, or<br />
hazardous to cells in any way and includes most anti-cancer drugs.”<br />
Where cytotoxic drugs are present in the workplace the employer<br />
must ensure that the legal requirements are being met.<br />
When you see this symbol, it indicates a specific legal<br />
requirement from the Occupational Health and <strong>Safe</strong>ty<br />
Regulation (the Regulation) when cytotoxic drugs are<br />
present in the workplace.<br />
2<br />
Best Practices for the <strong>Safe</strong> <strong>Handling</strong> <strong>of</strong> <strong>Hazardous</strong> <strong>Drugs</strong>
Part 1: <strong>Hazardous</strong> drugs<br />
in the workplace<br />
The following chapters provide an overview <strong>of</strong> current knowledge on hazardous drugs.<br />
This will help you understand what hazardous drugs are, why they are hazardous, and<br />
who is at risk <strong>of</strong> exposure. Routes <strong>of</strong> occupational exposure are also covered, as well<br />
as what kind <strong>of</strong> information should be included in an exposure control plan.
1. What are hazardous drugs?<br />
<strong>Hazardous</strong> drugs are specific drugs with the potential to harm<br />
workers who are exposed to them. Continual or frequent exposures<br />
to low levels <strong>of</strong> hazardous drugs, or a single exposure to a larger<br />
amount, can put workers at risk <strong>of</strong> negative health effects.<br />
Refer to Appendix 1: References and Resources for a list <strong>of</strong> studies<br />
that provide evidence on the potential health risks <strong>of</strong> occupational<br />
exposure to hazardous drugs.<br />
This book uses the definition <strong>of</strong> a hazardous drug that the National<br />
Institute for Occupational Health and <strong>Safe</strong>ty (NIOSH) developed.<br />
According to NIOSH’s definition, a drug is hazardous if there is<br />
evidence <strong>of</strong> one or more <strong>of</strong> the following characteristics in humans<br />
or animals:<br />
••<br />
Carcinogenicity: the ability to cause cancer<br />
••<br />
Teratogenicity or other developmental toxicity: the ability to<br />
affect the development <strong>of</strong> an embryo or fetus<br />
••<br />
Reproductive toxicity: the ability to affect reproductive function<br />
in adults<br />
••<br />
Organ toxicity at low doses: the ability to seriously affect organs<br />
or organ systems<br />
••<br />
Genotoxicity: the ability to damage genetic material within cells<br />
NIOSH determines whether drugs meet these criteria by reviewing<br />
existing scientific evidence for each drug and then lists qualified<br />
drugs in a periodical. Visit the NIOSH <strong>Hazardous</strong> <strong>Drugs</strong> web page<br />
for the most recent list <strong>of</strong> hazardous drugs.<br />
For drugs not on the NIOSH list, employers can determine whether<br />
a drug is considered hazardous by using the following sources <strong>of</strong><br />
information:<br />
••<br />
Evidence-based research that indicates the drug meets the<br />
criteria for a hazardous drug<br />
••<br />
Drug information sheets provided by the manufacturer, such as<br />
safety data sheets<br />
••<br />
Product monographs in Health Canada’s Drug Product Database<br />
••<br />
Health warnings from government or pr<strong>of</strong>essional groups<br />
Best Practices for the <strong>Safe</strong> <strong>Handling</strong> <strong>of</strong> <strong>Hazardous</strong> <strong>Drugs</strong> 5
2. Who is at risk <strong>of</strong> exposure?<br />
A wide range <strong>of</strong> people can be at risk <strong>of</strong> exposure to hazardous<br />
drugs in their workplace, including:<br />
••<br />
Pharmacy workers<br />
••<br />
Laboratory workers<br />
••<br />
Nurses<br />
••<br />
Health care assistants<br />
••<br />
Cleaners, housekeeping and laundry staff<br />
••<br />
Physicians<br />
••<br />
Veterinary and animal attendant workers<br />
••<br />
Community health workers<br />
••<br />
Workers involved in drug shipping/receiving/transport services<br />
••<br />
Workers involved in hazardous waste services<br />
6<br />
Best Practices for the <strong>Safe</strong> <strong>Handling</strong> <strong>of</strong> <strong>Hazardous</strong> <strong>Drugs</strong>
3. Why are workers at risk?<br />
In the past most hazardous drugs were antineoplastic, which refers<br />
to drugs used to treat cancer. However, hazardous drugs are<br />
increasingly being used to treat diseases other than cancer, such as:<br />
••<br />
Rheumatoid arthritis<br />
••<br />
Skin psoriasis<br />
••<br />
Multiple sclerosis<br />
••<br />
Some viral diseases, such as HIV<br />
••<br />
Hormone-dependent cancers<br />
<strong>Hazardous</strong> drugs are increasingly being administered in nontraditional<br />
settings—including community or home care, and<br />
physician and veterinary practices. In these workplaces, there may<br />
not be well-established control measures in place to minimize<br />
occupational exposure. Part 3 touches on these workplaces and<br />
provides practical, task-based information on working with<br />
hazardous drugs in these environments.<br />
With the growing potential for exposure to hazardous drugs, it is<br />
essential that all workplaces where hazardous drugs are present<br />
have effective measures in place to control worker exposure.<br />
Best Practices for the <strong>Safe</strong> <strong>Handling</strong> <strong>of</strong> <strong>Hazardous</strong> <strong>Drugs</strong> 7
4. Routes <strong>of</strong> occupational exposure<br />
Workers can be exposed to hazardous drugs in a number <strong>of</strong> ways.<br />
The potential route <strong>of</strong> exposure depends on the form <strong>of</strong> the drug<br />
being handled and the tasks being conducted. The table on page 9<br />
shows the main routes <strong>of</strong> worker exposure and gives some examples<br />
<strong>of</strong> activities where these exposures may take place. It also gives<br />
examples <strong>of</strong> controls that may be used to minimize these routes <strong>of</strong><br />
exposure to workers.<br />
Surface contamination is one <strong>of</strong> the main sources <strong>of</strong> occupational<br />
exposure to hazardous drugs. Due to their chemical stability,<br />
residue from hazardous drugs can persist in the workplace<br />
and be spread far from their point <strong>of</strong> origin. Trace residue from<br />
hazardous drugs can deposit on surfaces, such as vials and IV<br />
bags containing hazardous drugs, work tables, and hazardous<br />
drug transport carts. Residue can also collect on items that are<br />
not directly used for handling hazardous drugs, such as pens,<br />
door handles, and elevator buttons. Since surfaces throughout<br />
the workplace may be contaminated, there is a potential risk <strong>of</strong><br />
exposure to others present in the workplace, including visiting<br />
staff or patient family members. Refer to Appendix 1 for scientific<br />
research on surface contamination.<br />
8<br />
Best Practices for the <strong>Safe</strong> <strong>Handling</strong> <strong>of</strong> <strong>Hazardous</strong> <strong>Drugs</strong>
Route <strong>of</strong> exposure Examples <strong>of</strong> activities Possible controls<br />
Direct dermal<br />
contact<br />
Indirect dermal<br />
contact<br />
Contact with eyes<br />
Inhalation<br />
Percutaneous<br />
exposure<br />
Ingestion<br />
••<br />
<strong>Handling</strong> oral or topical forms <strong>of</strong><br />
hazardous drugs<br />
••<br />
Contact with a leak or spill <strong>of</strong><br />
hazardous drugs<br />
••<br />
<strong>Handling</strong> contaminated patient<br />
excreta<br />
••<br />
<strong>Handling</strong> or touching contaminated<br />
materials, such as equipment,<br />
containers, work surfaces, patient<br />
laundry<br />
••<br />
<strong>Handling</strong> liquid forms <strong>of</strong> hazardous<br />
drugs<br />
••<br />
Inhaling aerosols or vapours<br />
released when priming equipment<br />
••<br />
Inhaling particulate material<br />
released when crushing tablets or<br />
opening capsules<br />
••<br />
Preparing or administering drugs<br />
using a needle<br />
••<br />
Eating food that has been<br />
contaminated with hazardous<br />
drugs<br />
••<br />
Wearing double<br />
chemotherapy-tested gloves<br />
••<br />
Using a closed-system transfer<br />
device<br />
••<br />
Wearing double<br />
chemotherapy-tested gloves<br />
••<br />
Observing a precautionary<br />
period for handling patient<br />
excreta<br />
••<br />
Wearing eye protection or a<br />
face shield<br />
••<br />
Performing activities inside a<br />
biological safety cabinet<br />
••<br />
Wearing an appropriate<br />
respirator<br />
••<br />
Using a needleless system or<br />
safety engineered medical<br />
sharp<br />
••<br />
Ensuring all food is stored away<br />
from areas where hazardous<br />
drugs are handled<br />
••<br />
Proper hand washing<br />
The selection <strong>of</strong> appropriate controls is discussed in Chapter 9.<br />
Refer to Appendix 1 for additional resources that provide scientific evidence for these routes <strong>of</strong><br />
exposure.<br />
Best Practices for the <strong>Safe</strong> <strong>Handling</strong> <strong>of</strong> <strong>Hazardous</strong> <strong>Drugs</strong> 9
5. Creating an exposure control plan<br />
In the Regulation<br />
Workplaces where<br />
cytotoxic drugs are<br />
present must have an<br />
exposure control plan<br />
in place. See sections<br />
5.54(1) and 6.43 <strong>of</strong><br />
the Regulation.<br />
The employer must<br />
review the exposure<br />
control plan at least<br />
annually and update<br />
if required. See<br />
section 5.54(3) <strong>of</strong> the<br />
Regulation.<br />
In the Regulation<br />
Where cytotoxic<br />
drugs are present in<br />
the workplace, the<br />
exposure control<br />
plan for the must be<br />
periodically reviewed.<br />
See section 5.54 <strong>of</strong><br />
the Regulation.<br />
An exposure control plan (ECP) describes how workers will be<br />
protected from hazardous drugs in the workplace. An ECP includes<br />
information on the nature <strong>of</strong> the hazard and the risk associated with<br />
exposure, as well as controls that the employer will use to protect<br />
workers.<br />
The ECP includes the following components, which are detailed in<br />
section 5.54(2) <strong>of</strong> the Regulation:<br />
••<br />
Statement <strong>of</strong> purpose and responsibilities<br />
••<br />
Risk identification and assessment<br />
••<br />
Risk controls<br />
••<br />
Written safe work procedures<br />
••<br />
Education and training<br />
••<br />
Written records<br />
••<br />
Hygiene facilities and decontamination procedures (when<br />
required)<br />
••<br />
Health monitoring (when required)<br />
The ECP should be reviewed at least annually and updated as<br />
necessary by the employer, in consultation with the joint<br />
occupational health and safety committee or the worker health and<br />
safety representative.<br />
10<br />
Best Practices for the <strong>Safe</strong> <strong>Handling</strong> <strong>of</strong> <strong>Hazardous</strong> <strong>Drugs</strong>
Part 2: Performing a risk<br />
assessment for hazardous<br />
drugs<br />
Chapters 6 to 9 detail the three steps involved in a risk assessment: identifying<br />
hazardous drugs, assessing risk <strong>of</strong> exposure, and implementing controls to eliminate or<br />
minimize exposure.<br />
Chapter 10 explains written safe work procedures and Chapter 11 outlines the<br />
different ways that hazardous drugs are labelled and communicated, as well as<br />
individual education and training.
6. What is a risk assessment?<br />
In the Regulation<br />
Risk assessments<br />
must be performed<br />
where cytotoxic<br />
drugs are present.<br />
See section 5.54(2) <strong>of</strong><br />
the Regulation.<br />
A risk assessment provides a foundation for eliminating or<br />
minimizing worker exposure to hazardous drugs in your workplace.<br />
It involves examining the level to which workers are being exposed<br />
to hazardous drugs and what can be done to reduce that exposure<br />
as much as practicable.<br />
A risk assessment involves performing the following three steps,<br />
which are discussed in more detail in the subsequent chapters:<br />
••<br />
Identify hazardous drugs that are present in the workplace.<br />
••<br />
Assess the risks <strong>of</strong> exposure to hazardous drugs.<br />
••<br />
Develop and implement controls to eliminate or reduce exposure.<br />
A risk assessment should be performed by an individual or team<br />
who, through a combination <strong>of</strong> education, training, and experience,<br />
are knowledgeable about the work, the hazards involved, and the<br />
means to control the hazards.<br />
Throughout this process, it‘s essential that front-line workers and<br />
representatives from the joint occupational health and safety<br />
committee <strong>of</strong> your workplace are consulted. Workers and their<br />
representatives provide knowledge on how work is being done and<br />
insight into potential solutions. The most effective solutions to<br />
controlling exposure will take the needs and knowledge <strong>of</strong> the<br />
worker into account.<br />
Best Practices for the <strong>Safe</strong> <strong>Handling</strong> <strong>of</strong> <strong>Hazardous</strong> <strong>Drugs</strong> 13
The following diagram shows the steps to performing a risk assessment.<br />
Employee<br />
Consultation<br />
Health and safety<br />
representative<br />
Hazard identification<br />
Risk assessment<br />
Risk control<br />
Elimination (<strong>of</strong> the hazard)<br />
Substitution<br />
Engineering<br />
Evaluation <strong>of</strong> controls<br />
Administration<br />
Personal<br />
protective<br />
equipment<br />
Trial and implement controls<br />
Permission provided by Work<strong>Safe</strong> Victoria to reproduce this diagram.<br />
14<br />
Best Practices for the <strong>Safe</strong> <strong>Handling</strong> <strong>of</strong> <strong>Hazardous</strong> <strong>Drugs</strong>
7. Identifying hazardous drugs<br />
In the Regulation<br />
A list <strong>of</strong> cytotoxic<br />
drugs must be<br />
created if they<br />
are present in the<br />
workplace. See<br />
section 6.47 <strong>of</strong> the<br />
Regulation.<br />
Identifying hazards is the first step toward controlling exposure to<br />
hazardous drugs in your workplace. This involves creating an<br />
inventory <strong>of</strong> all drugs in the workplace and then determining<br />
whether hazardous drugs are present among them.<br />
Create a list <strong>of</strong> hazardous drugs in your workplace<br />
Once you’ve listed all the drugs that are present in your workplace,<br />
compare them with known hazardous drugs. Visit the following<br />
websites to view the most recent hazardous drug lists:<br />
••<br />
BC Cancer Agency<br />
••<br />
NIOSH <strong>Hazardous</strong> <strong>Drugs</strong><br />
If you don’t find a drug on the list, it should be reviewed to determine<br />
if it is hazardous, using the criteria discussed in Chapter 1.<br />
Document hazardous drug details<br />
Once the presence <strong>of</strong> hazardous drugs in the workplace has been<br />
established, information needs to be gathered and reviewed for each<br />
hazardous drug. The following table shows the potential routes <strong>of</strong><br />
exposure, the form <strong>of</strong> the substance, and the potential health effects.<br />
Best Practices for the <strong>Safe</strong> <strong>Handling</strong> <strong>of</strong> <strong>Hazardous</strong> <strong>Drugs</strong> 15
Obtain and review information about hazardous drugs used<br />
Determine the routes<br />
<strong>of</strong> exposure.<br />
Determine the form <strong>of</strong><br />
the substance.<br />
Ascertain the potential<br />
harmful effects.<br />
These may include:<br />
••<br />
Inhalation <strong>of</strong> aerosols, particulates, and droplets<br />
••<br />
Skin or eye contact through splash <strong>of</strong> liquid<br />
••<br />
Ingestion through poor personal hygiene or splash <strong>of</strong> liquid<br />
••<br />
Injection resulting from injuries from sharps<br />
This may include:<br />
••<br />
Liquid<br />
••<br />
Powder<br />
••<br />
Tablet<br />
••<br />
Creams, ointments, and lotions for topical application<br />
These may include:<br />
••<br />
Carcinogenic, mutagenic, or teratogenic potential<br />
••<br />
Alterations to normal blood cell count<br />
••<br />
Fetal loss in pregnant women and malfunctions in the <strong>of</strong>fspring <strong>of</strong><br />
pregnant women<br />
••<br />
Abnormal pain, hair loss, nasal sores, vomiting<br />
••<br />
Liver damage<br />
••<br />
Contact dermatitis, local toxic or allergic reaction, irritation to the skin<br />
Approval to reproduce adapted version from Work<strong>Safe</strong> Victoria.<br />
16<br />
Best Practices for the <strong>Safe</strong> <strong>Handling</strong> <strong>of</strong> <strong>Hazardous</strong> <strong>Drugs</strong>
8. Assessing risk<br />
In the Regulation<br />
A risk assessment<br />
must be performed<br />
where cytotoxic drugs<br />
are present. See<br />
sections 5.54(2)(b) and<br />
6.43 <strong>of</strong> the Regulation.<br />
Once the presence <strong>of</strong> hazardous drugs has been identified, the next<br />
step is to determine the level <strong>of</strong> risk. This involves determining how<br />
the drugs are used in the workplace and identifying which tasks<br />
place workers at risk <strong>of</strong> exposure.<br />
Evaluation involves analyzing the work environment, tasks and<br />
activities performed, and any previous incidents where workers<br />
may have been exposed to hazardous drugs. This information can<br />
be gathered by performing a walk-through survey <strong>of</strong> the workplace,<br />
consulting with workers who are performing the tasks being<br />
evaluated, and reviewing employer health and safety records. See<br />
the following table for more details.<br />
Evaluate the nature <strong>of</strong> the work involving hazardous drugs<br />
Divide up the<br />
workplace and<br />
determine where<br />
hazardous drugs are<br />
used.<br />
Examine the work<br />
practices and<br />
conditions.<br />
Involve employees<br />
who are working with<br />
the hazardous drugs.<br />
Review information<br />
relating to incidents<br />
or symptons <strong>of</strong><br />
exposure.<br />
For example:<br />
••<br />
Drug preparation in the pharmacy<br />
••<br />
Drug administration in the ward or daycare centre<br />
••<br />
<strong>Handling</strong>, transport, and disposal <strong>of</strong> hazardous waste on the<br />
premises<br />
••<br />
Patient care after adminstration<br />
What to look for:<br />
••<br />
How substances are used in various jobs<br />
••<br />
The quantities used<br />
••<br />
Level <strong>of</strong> potential exposure<br />
••<br />
Frequency and duration <strong>of</strong> use<br />
••<br />
The number <strong>of</strong> employees that may be exposed<br />
••<br />
Risk control measures already in place and their effectiveness<br />
What to do:<br />
••<br />
Review incident records.<br />
••<br />
Identify any problems associated with storage and transport <strong>of</strong><br />
hazardous drugs.<br />
••<br />
Determine whether employees have suffered any adverse effects.<br />
••<br />
Ascertain whether there have been any spills.<br />
••<br />
Determine if incidents have been reported and followed up.<br />
Approval to reproduce adapted version from Work<strong>Safe</strong> Victoria.<br />
Best Practices for the <strong>Safe</strong> <strong>Handling</strong> <strong>of</strong> <strong>Hazardous</strong> <strong>Drugs</strong> 17
8.1 Tools for assessing risk<br />
You can use one or all <strong>of</strong> the following assessment tools to help<br />
you determine the level <strong>of</strong> risk posed by hazardous drugs in your<br />
workplace:<br />
••<br />
Categorizing hazardous drugs<br />
••<br />
Environmental monitoring<br />
••<br />
Health monitoring<br />
Categorizing hazardous drugs<br />
For workplaces that use a wide variety or a large number <strong>of</strong><br />
hazardous drugs, it may be helpful to categorize them in terms <strong>of</strong><br />
the degree <strong>of</strong> risk <strong>of</strong> exposure. This may make it easier for the<br />
employer to communicate to workers situations where they are at<br />
high risk <strong>of</strong> exposure. This would be based on information about<br />
the drug itself, such as the form <strong>of</strong> the drug, potential routes <strong>of</strong><br />
exposure, and potential health effects, as well as information on the<br />
how the drug is used in the workplace, as determined in the risk<br />
assessment.<br />
Check to see if your workplace uses a hazardous drug classification<br />
system for assessing hazardous drugs.<br />
Categorizing hazardous drugs may help when developing safe<br />
handling practices that are based on the risk <strong>of</strong> worker exposure<br />
and are suitable for each stage <strong>of</strong> handling hazardous drugs.<br />
Categorizing hazardous drugs is a tool that may be used for<br />
assessing risk, or you may find that other means are more useful or<br />
practicable in your workplace.<br />
Environmental monitoring<br />
Another tool that may be used as part <strong>of</strong> the risk assessment process<br />
is environmental monitoring. For example, surface wipe sampling<br />
measures surface contamination <strong>of</strong> selected sites <strong>of</strong> the work<br />
environment by taking wipe samples and analyzing them in a<br />
laboratory for the presence <strong>of</strong> hazardous drug contamination.<br />
Sampling surfaces throughout the workplace can help provide a<br />
picture <strong>of</strong> how hazardous drug contamination is spread throughout<br />
different stages <strong>of</strong> handling. Refer to Appendix 3 for more<br />
information on environmental monitoring.<br />
<strong>Hazardous</strong> drug contamination throughout the workplace should<br />
be kept as low as possible. The goal <strong>of</strong> environmental monitoring, if<br />
it is used, is to establish baseline measurements <strong>of</strong> hazardous drug<br />
contamination in the workplace with which future measurements<br />
can be compared. Future measurements can be monitored for<br />
18<br />
Best Practices for the <strong>Safe</strong> <strong>Handling</strong> <strong>of</strong> <strong>Hazardous</strong> <strong>Drugs</strong>
eductions in contamination over a period <strong>of</strong> time or as the result <strong>of</strong><br />
interventions that have been implemented. These comparisons can<br />
help determine areas where interventions were successful and set<br />
targets for future improvements.<br />
Health monitoring<br />
Health monitoring is intended to prevent the development <strong>of</strong><br />
occupational disease in workers by detecting biomarkers in blood<br />
or urine samples that indicate early signs <strong>of</strong> disease. For hazardous<br />
drugs, this can be difficult in practice because the health outcomes<br />
due to exposure are not yet fully understood.<br />
There are also methods to detect hazardous drugs (or their<br />
metabolites) in blood or urine. These tests should always be<br />
interpreted with caution, as detecting signs <strong>of</strong> exposure does not<br />
necessarily mean that disease will develop.<br />
Health monitoring is typically used in a research setting. If health<br />
monitoring is used in the workplace, it can help inform a risk<br />
assessment by tracking whether worker exposure to hazardous<br />
drugs changes over a period <strong>of</strong> time. However, health monitoring is<br />
not a required component <strong>of</strong> an exposure control plan since these<br />
methods are not all easily available or validated.<br />
Best Practices for the <strong>Safe</strong> <strong>Handling</strong> <strong>of</strong> <strong>Hazardous</strong> <strong>Drugs</strong> 19
9. Developing and implementing<br />
control measures<br />
In the Regulation<br />
Control measures<br />
must be identified<br />
where cytotoxic<br />
drugs are present in<br />
the workplace and<br />
implemented in the<br />
order shown. See<br />
section 5.5 <strong>of</strong> the<br />
Regulation.<br />
Once all hazardous drugs have been identified and the risks<br />
assessed, appropriate controls should be chosen that reduce the<br />
risk <strong>of</strong> exposure to workers. Controls aim to eliminate or reduce<br />
exposure to workers. As shown in the diagram below, one or more<br />
<strong>of</strong> these controls should be implemented in the following order:<br />
(1) Elimination or substitution<br />
(2) Engineering controls<br />
(3) Administrative controls<br />
(4) Personal protective equipment (PPE)<br />
Most<br />
effective<br />
Elimination/substitution<br />
Physically remove or<br />
replace the hazard<br />
Engineering controls<br />
Isolate workers<br />
from the hazard<br />
Administrative &<br />
work practices<br />
controls<br />
Change the way<br />
workers work<br />
PPE<br />
Protect workers with<br />
personal protective equipment<br />
Least<br />
effective<br />
20<br />
Best Practices for the <strong>Safe</strong> <strong>Handling</strong> <strong>of</strong> <strong>Hazardous</strong> <strong>Drugs</strong>
The following table provides a description and examples for each type <strong>of</strong> control.<br />
Type <strong>of</strong> Control Description Examples<br />
Elimination<br />
Substitution<br />
Engineering<br />
controls<br />
Administrative<br />
controls<br />
PPE<br />
Elimination <strong>of</strong> hazardous drugs<br />
from the workplace is not typically<br />
possible because these drugs may<br />
be the only treatment available.<br />
Substitution includes using<br />
a drug that is less hazardous,<br />
either because <strong>of</strong> the form it is<br />
administered in or its toxicological<br />
properties (provided it is just as<br />
effective at treating the patient).<br />
Engineering controls protect<br />
workers by physically changing<br />
the work environment to minimize<br />
exposure to hazardous drugs.<br />
Administrative controls aim<br />
to reduce exposure in the work<br />
environment by changing how<br />
work is carried out.<br />
PPE controls exposure at the point<br />
<strong>of</strong> the individual worker. It is last in<br />
the hierarchy <strong>of</strong> controls because<br />
it requires the most activity and<br />
is the least effective means <strong>of</strong><br />
limiting worker exposure. PPE will<br />
<strong>of</strong>ten have to be worn despite the<br />
presence <strong>of</strong> other control methods.<br />
••<br />
Removing unneeded hazardous<br />
drugs from the workplace<br />
••<br />
Having drugs delivered in a form<br />
that is ready to administer<br />
••<br />
Eliminating the number <strong>of</strong> times<br />
hazardous drugs are handled<br />
••<br />
Using a form <strong>of</strong> hazardous drugs<br />
that has a lower risk <strong>of</strong> exposure<br />
to workers, such as tablets instead<br />
<strong>of</strong> IV infusions (if clinically<br />
appropriate)<br />
••<br />
Using an appropriate biological<br />
safety cabinet<br />
••<br />
Having negative pressure<br />
preparation rooms or anterooms<br />
••<br />
Using closed-system transfer<br />
devices<br />
••<br />
Regular hand washing<br />
••<br />
Implementing an effective<br />
cleaning routine<br />
••<br />
Protective reassignment<br />
••<br />
Developing and implementing<br />
safe work procedures<br />
••<br />
Chemotherapy-tested gloves<br />
••<br />
Chemotherapy-tested gowns<br />
••<br />
Respirators<br />
••<br />
Eye and face protection<br />
••<br />
Footwear and shoe covers<br />
Best Practices for the <strong>Safe</strong> <strong>Handling</strong> <strong>of</strong> <strong>Hazardous</strong> <strong>Drugs</strong> 21
Workers exposed to reproductive toxins: protective<br />
reassignment<br />
Some hazardous drugs may also be reproductive toxins. According<br />
to section 6.49 <strong>of</strong> the Regulation, where reproductive toxins are<br />
present in cytotoxic drugs, the employer must develop procedures<br />
to reduce the risk <strong>of</strong> exposure to workers who are pregnant or who<br />
are trying to conceive a child.<br />
An administrative control method <strong>of</strong> achieving this is protective<br />
reassignment. This is where the worker is assigned to alternative<br />
tasks that reduce the risk <strong>of</strong> their exposure to hazardous drugs.<br />
Some examples <strong>of</strong> protective reassignment include, but are not<br />
limited to:<br />
••<br />
Moving the worker to a different area that does not involve<br />
exposure to hazardous drugs<br />
••<br />
Assigning the worker to tasks where they won’t be exposed to<br />
hazardous drugs<br />
••<br />
Reducing shift hours working in areas where hazardous drugs<br />
are handled<br />
22<br />
Best Practices for the <strong>Safe</strong> <strong>Handling</strong> <strong>of</strong> <strong>Hazardous</strong> <strong>Drugs</strong>
10. Written safe work procedures<br />
In the Regulation<br />
<strong>Safe</strong> work procedures<br />
must be in place<br />
and posted where<br />
cytotoxic drugs<br />
are present in the<br />
workplace. See<br />
section 6.48 <strong>of</strong> the<br />
Regulation.<br />
Written safe work procedures that are specific to the tasks<br />
performed at the workplace are an important part <strong>of</strong> ensuring that<br />
information on minimizing exposure is communicated to workers.<br />
<strong>Safe</strong> work procedures must be available to workers.<br />
Examples <strong>of</strong> safe work procedures to be developed and<br />
communicated to workers include:<br />
••<br />
Appropriate safe work procedures for all tasks and activities<br />
involving hazardous drugs, including but not limited to, receiving,<br />
storage, preparation, administration, and waste handling<br />
••<br />
PPE requirements for each stage <strong>of</strong> handling and related worker<br />
and employer responsibilities<br />
••<br />
Requirements for proper hygiene, including proper hand washing<br />
and the prohibition <strong>of</strong> eating, drinking, smoking, applying<br />
cosmetics, and storing food where hazardous drugs are present<br />
••<br />
Procedures for documenting acute exposures and reporting<br />
suspected exposures<br />
••<br />
Procedures for emergency spills, including medical treatment<br />
and personnel decontamination for acute exposures and proper<br />
cleanup<br />
••<br />
Procedures for hazardous drug waste disposal<br />
Best Practices for the <strong>Safe</strong> <strong>Handling</strong> <strong>of</strong> <strong>Hazardous</strong> <strong>Drugs</strong> 23
11. Information and communication<br />
In the Regulation<br />
Where cytotoxic<br />
drugs are present<br />
in the workplace,<br />
information must<br />
be communicated<br />
to workers in the<br />
form <strong>of</strong> labels, signs,<br />
lists, education and<br />
training, and written<br />
records. See sections<br />
6.45, 6.46, 6.47,<br />
6.50, and 6.52 <strong>of</strong> the<br />
Regulation.<br />
[Picture: Sample <strong>Hazardous</strong> <strong>Drugs</strong> Warning Labe<br />
In Canada, drug products fall under the jurisdiction <strong>of</strong> the Food<br />
and <strong>Drugs</strong> Act and are exempt from WHMIS requirements.<br />
However, information requirements under section 5.2 <strong>of</strong> the<br />
Regulation still apply. These requirements include communicating<br />
information about hazardous drugs to workers via:<br />
••<br />
Labels, signs, and lists<br />
••<br />
Education and training<br />
••<br />
Written records<br />
Labels, signs, and lists<br />
CAUTION CHEMOTHERAPY<br />
Authorized Personnel Only<br />
If workers are exposed to hazardous drugs, this information must<br />
be communicated to workers, including those who may not be<br />
pr<strong>of</strong>icient in English. This may be done by:<br />
••<br />
Ensuring all hazardous drugs are labelled to identify them as<br />
hazardous<br />
••<br />
Posting warning signs to workers in areas where hazardous drugs<br />
are present<br />
••<br />
Maintaining a list <strong>of</strong> all hazardous drugs present in the workplace<br />
: Sample <strong>Hazardous</strong> <strong>Drugs</strong> Warning Labels and Signs]<br />
CAUTION CHEMOTHERAPY<br />
Authorized Personnel Only<br />
24<br />
Best Practices for the <strong>Safe</strong> <strong>Handling</strong> <strong>of</strong> <strong>Hazardous</strong> <strong>Drugs</strong>
11.1 Education and training<br />
Training is an essential component <strong>of</strong> reducing exposure to<br />
hazardous drugs in occupational settings. It is the employer’s<br />
responsibility to ensure that workers are informed about the<br />
exposure control plan for their workplace.<br />
All workers who are potentially exposed to hazardous drugs must<br />
receive education on known health risks, including any potential<br />
reproductive hazards and, where appropriate, training on:<br />
••<br />
Relevant techniques and procedures for safe handling<br />
••<br />
Proper use <strong>of</strong> relevant equipment and materials<br />
••<br />
Spill and waste disposal procedures<br />
••<br />
Procedures for reporting known exposures and suspected health<br />
effects<br />
11.2 Written records<br />
All components <strong>of</strong> an exposure control plan for hazardous drugs<br />
should be documented, including periodic reviews. Maintaining<br />
records is useful for demonstrating compliance with the Regulation.<br />
Best Practices for the <strong>Safe</strong> <strong>Handling</strong> <strong>of</strong> <strong>Hazardous</strong> <strong>Drugs</strong> 25
Part 3: Task-specific<br />
guidelines for reducing<br />
exposure to hazardous<br />
drugs<br />
The following chapters provide information for making changes in the workplace at<br />
each stage <strong>of</strong> handling hazardous drugs. The practices that your workplace chooses to<br />
adopt should be based on the findings <strong>of</strong> the risk assessment, with the goal <strong>of</strong><br />
minimizing worker exposure to hazardous drugs.
12. Drug shipping<br />
Containers or packages <strong>of</strong> hazardous drugs can potentially be a<br />
source <strong>of</strong> exposure to workers involved in shipping hazardous drugs<br />
to facilities where they are prepared or administered. This is because<br />
it’s possible there may already be surface contamination on the<br />
outside <strong>of</strong> the packaging from the manufacturing stage. Shipments<br />
may also be damaged during transport resulting in leaks or spills.<br />
Potential activities that could result in exposure include:<br />
••<br />
Surface contamination on the exterior <strong>of</strong> shipping packaging<br />
••<br />
Leaks or spills during transport<br />
Refer to Appendix 1 for references regarding surface contamination.<br />
Guidelines for safe work practice<br />
Drug suppliers and shipping companies handling hazardous drugs<br />
should ensure that there are appropriate procedures in place to<br />
protect their workers from exposure to hazardous drugs.<br />
Best practices for purchasing and shipping <strong>of</strong> hazardous drugs<br />
include:<br />
••<br />
Sealing hazardous drugs in plastic bags or shrink wrap during<br />
transport<br />
••<br />
Ensuring there are warning labels on the outside <strong>of</strong> shipping or<br />
transport containers containing hazardous drugs<br />
••<br />
Using packages and packaging methods that will minimize<br />
breakage<br />
In the Regulation<br />
PPE that is consistent<br />
with the ECP must be<br />
used where cytotoxic<br />
drugs are present.<br />
See section 6.55 <strong>of</strong><br />
the Regulation.<br />
Personal protective equipment (PPE)<br />
PPE must be consistent with the worker’s potential exposure and<br />
may include:<br />
••<br />
Chemotherapy-tested gloves<br />
••<br />
A chemotherapy-tested gown<br />
Refer to Appendix 4 for further details on PPE.<br />
Best Practices for the <strong>Safe</strong> <strong>Handling</strong> <strong>of</strong> <strong>Hazardous</strong> <strong>Drugs</strong> 29
13. Drug receiving and storage<br />
Surface contamination <strong>of</strong> containers and packaging is a potential<br />
source <strong>of</strong> exposure for workers as they unpack and store incoming<br />
shipments <strong>of</strong> hazardous drugs. Facilities should communicate with<br />
the drug suppliers to identify hazardous drugs during shipping and<br />
reduce exposure for the workers transporting and receiving the drugs.<br />
Potential activities that could result in exposure include:<br />
••<br />
<strong>Handling</strong> incoming shipments <strong>of</strong> hazardous drugs that may<br />
have surface contamination<br />
••<br />
Opening packages containing hazardous drugs, which could<br />
result in the generation <strong>of</strong> particulates or aerosol<br />
••<br />
<strong>Handling</strong> individual containers or bags <strong>of</strong> hazardous drugs that<br />
may have surface contamination<br />
••<br />
<strong>Handling</strong> damaged packaging that has resulted in a leak or<br />
spill<br />
Incoming shipments may also be damaged or broken, in which<br />
case proper spill procedures need to be taken (refer to Chapter 21).<br />
13.1 Work area design<br />
<strong>Hazardous</strong> drugs may be received in a receiving bay or in a<br />
designated room or area <strong>of</strong> a pharmacy before being stored in a<br />
storage area. In order to minimize exposure, areas where hazardous<br />
drugs are received or stored should be built and organized to<br />
minimize exposure.<br />
Receiving and storage areas should:<br />
••<br />
Be in a designated area, preferably separated from the rest <strong>of</strong> the<br />
facility<br />
••<br />
Have negative pressure with respect to surrounding rooms<br />
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Best Practices for the <strong>Safe</strong> <strong>Handling</strong> <strong>of</strong> <strong>Hazardous</strong> <strong>Drugs</strong>
13.2 Equipment<br />
Equipment used in receiving and storage areas should, where<br />
possible, be designed to minimize potential exposure to hazardous<br />
drugs. Examples include:<br />
••<br />
Storage shelves with fall guards, such as lipped edges or barriers<br />
••<br />
Containers with lids for storage and transport <strong>of</strong> hazardous drugs<br />
••<br />
Equipment that can accommodate special storage requirements,<br />
such as a refrigerator for drugs that require cooler temperatures<br />
13.3 Guidelines for safe work practice<br />
Best practices to eliminate and minimize the risk to hazardous drugs<br />
during receiving and storage include:<br />
••<br />
Having incoming shipments checked for damage before any<br />
container is opened<br />
••<br />
Implementing a procedure to clean containers before they are<br />
moved to storage, such as wiping the exterior with a single-use<br />
disposable absorbent pad and a detergent and water solution<br />
••<br />
Limiting access to the storage area and using signs to indicate<br />
restricted entry to authorized personnel only<br />
••<br />
Storing hazardous drugs inside their original packaging (for<br />
example, resealable bags or shrink wrap)<br />
••<br />
Ensuring storage containers are not overfilled<br />
13.4 Personal protective equipment (PPE)<br />
In the Regulation<br />
PPE that is consistent<br />
with the ECP must be<br />
used where cytotoxic<br />
drugs are present.<br />
See section 6.55 <strong>of</strong><br />
the Regulation.<br />
PPE must be consistent with the worker’s potential exposure and<br />
may include:<br />
••<br />
Chemotherapy-tested gloves<br />
••<br />
A chemotherapy-tested gown<br />
••<br />
An approved and fit-tested respirator, if handling damaged<br />
packages containing hazardous drugs<br />
Refer to Appendix 4 for further details on PPE.<br />
Best Practices for the <strong>Safe</strong> <strong>Handling</strong> <strong>of</strong> <strong>Hazardous</strong> <strong>Drugs</strong> 31
14. Drug transport<br />
Workers who transport hazardous drugs throughout a facility may<br />
be exposed if they come into contact with hazardous drug surface<br />
contamination or a hazardous drug leak or spill.<br />
Potential activities that could result in exposure include:<br />
••<br />
<strong>Handling</strong> containers or packages with hazardous drug surface<br />
contamination<br />
••<br />
<strong>Handling</strong> containers or packages when there has been a leak<br />
or a spill<br />
14.1 Equipment<br />
The equipment used for transporting hazardous drugs throughout a<br />
facility should be designed to minimize exposure to workers<br />
handling hazardous drug products. This includes:<br />
••<br />
Equipment that reduces spills, such as carts with lipped edges<br />
and closed, hard-sided transport boxes<br />
••<br />
Using equipment that is easy to clean<br />
14.2 Guidelines for safe work practice<br />
Best practices for transporting hazardous drugs include:<br />
••<br />
Using resealable clear plastic bags to place hazardous drug<br />
products in before transport<br />
••<br />
Using closed, hard-sided boxes to be used for transport<br />
throughout the facility<br />
••<br />
Implementing procedures for safe handling <strong>of</strong> products during<br />
transport<br />
In the Regulation<br />
PPE that is consistent<br />
with the ECP must be<br />
used where cytotoxic<br />
drugs are present.<br />
See section 6.55 <strong>of</strong><br />
the Regulation.<br />
14.3 Personal protective equipment (PPE)<br />
PPE must be consistent with the worker’s potential exposure and<br />
may include:<br />
••<br />
Double chemotherapy-tested gloves<br />
••<br />
A chemotherapy-tested gown<br />
Refer to Appendix 4 for more details on PPE.<br />
32<br />
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15. Drug preparation<br />
A preparation room is where drugs are prepared, compounded, and<br />
verified before they are administered to patients. Workers may<br />
work directly with hazardous drugs. Care must be taken to minimize<br />
exposure during handling and to limit the spread <strong>of</strong> hazardous drug<br />
contamination.<br />
Potential activities that could result in exposure include:<br />
••<br />
Compounding, diluting, or altering hazardous drug medications<br />
••<br />
Priming administration equipment, which can generate aerosol<br />
or particulate contamination<br />
••<br />
<strong>Handling</strong>, crushing, or opening oral medications<br />
••<br />
<strong>Handling</strong> hazardous drugs while verifying before they leave the<br />
pharmacy, as packaging may have surface contamination<br />
15.1 Work area design<br />
Preparation rooms can be sterile or non-sterile, depending on the<br />
conditions that are required for the task being performed. A sterile<br />
preparation room (which may also be called a clean room) should<br />
not be used for compounding non-sterile preparations.<br />
Refer to the following resources for detailed information on clean<br />
room specifications:<br />
••<br />
NAPRA “Model Standards for Pharmacy Compounding <strong>of</strong><br />
<strong>Hazardous</strong> Sterile Products”<br />
••<br />
USP Chapter “Pharmaceutical Compounding - Sterile<br />
Preparations”<br />
••<br />
USP Chapter “<strong>Hazardous</strong> <strong>Drugs</strong> - <strong>Handling</strong> in Healthcare<br />
Settings”<br />
Sterile preparation rooms should:<br />
••<br />
Be an ISO Class 7 environment, if the room contains a biological<br />
safety cabinet for sterile preparations<br />
••<br />
Exhaust all air through at least one high efficiency particulate air<br />
(HEPA) filter before being exhausted externally from the building<br />
••<br />
Have an ISO Class 7 anteroom through which personnel enter,<br />
with interlocking doors that cannot be opened at the same time<br />
••<br />
Use pass-through hatches for the transfer <strong>of</strong> preparations out <strong>of</strong><br />
the room<br />
Best Practices for the <strong>Safe</strong> <strong>Handling</strong> <strong>of</strong> <strong>Hazardous</strong> <strong>Drugs</strong> 33
••<br />
Have a viewing window and an intercom system so workers can<br />
communicate with workers outside the room<br />
••<br />
Have furniture and equipment made <strong>of</strong> materials that are easily<br />
cleaned and decontaminated, such as stainless steel<br />
Non-sterile preparation rooms are where hazardous drugs can be<br />
prepared in non-sterile conditions, such as splitting or crushing oral<br />
medications, repackaging medications into dosettes, preparing oral<br />
solutions, or preparing topical creams.<br />
Non-sterile preparation rooms should:<br />
••<br />
Be kept under negative pressure with respect to surrounding rooms<br />
••<br />
Be a separate room that is dedicated for non-sterile hazardous<br />
drug preparations<br />
••<br />
Exhaust all air externally<br />
••<br />
Use furniture and equipment made <strong>of</strong> materials that are easily<br />
cleaned and decontaminated, such as stainless steel<br />
15.2 Equipment<br />
The equipment used during the preparation <strong>of</strong> hazardous drugs<br />
should be selected based on their effectiveness at reducing worker<br />
exposure to hazardous drugs.<br />
In the Regulation<br />
Where preparation<br />
activities involving<br />
cytotoxic drugs take<br />
place at the facility,<br />
an approved BSC<br />
must be provided and<br />
used. See section<br />
6.53(1)(a)(b) <strong>of</strong> the<br />
Regulation.<br />
Biological safety cabinets<br />
A biological safety cabinet (BSC) is a ventilated containment<br />
cabinet that is designed to provide personnel, product, and<br />
environmental protection.<br />
Not all BSCs are appropriate for use with hazardous drugs. BSCs<br />
that are used for preparing hazardous drugs should:<br />
••<br />
Be exhausted to the outside atmosphere to prevent recirculation<br />
into the preparation room<br />
••<br />
Have exhaust and ventilation systems that operate continuously<br />
to ensure that no contaminants escape from the biological safety<br />
cabinet into the workplace<br />
BSCs are divided into three classes (Class I, Class II, and Class III)<br />
that are each designed to meet different needs depending on their<br />
intended use. In workplaces where both sterile and non-sterile<br />
preparations take place, it is best practice to have a separate BSC<br />
dedicated for each purpose.<br />
Refer to Appendix 5 for additional information on the selection <strong>of</strong><br />
an appropriate BSC.<br />
34<br />
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In the Regulation<br />
Where a BSC is used,<br />
it must be equipped<br />
with a continuous<br />
airflow monitoring<br />
device where<br />
cytotoxic drugs are<br />
present. See section<br />
6.53(1)(c) <strong>of</strong> the<br />
Regulation.<br />
Performance testing <strong>of</strong> BSCs<br />
Performance testing <strong>of</strong> the preparation room equipment should<br />
take place regularly.<br />
All BSCs used for hazardous drugs should be equipped with a<br />
continuous airflow monitoring device to ensure adequate airflow<br />
and performance <strong>of</strong> the BSC before it is used to prepare hazardous<br />
drugs. Workers who use the BSC should regularly document the<br />
readings on the monitoring device and be able to recognize when<br />
the readings indicate a malfunctioning BSC, as well as appropriate<br />
procedures to follow if this occurs. <strong>Safe</strong> work procedures must be<br />
developed to ensure worker protection when a BSC is turned <strong>of</strong>f.<br />
BSCs must be regularly tested and certified to ensure that they are<br />
performing properly following the manufacturer’s specifications<br />
and the requirements <strong>of</strong> the Regulation.<br />
Closed-system transfer devices<br />
Closed-system transfer devices (CSTDs) are designed to contain<br />
hazardous drugs and minimize potential exposure when transferring<br />
hazardous drugs between containers or pieces <strong>of</strong> equipment.<br />
It is important to note that a CSTD is not a substitute for compounding<br />
preparations inside a BSC. When a CSTD is used during the<br />
preparation <strong>of</strong> hazardous drugs, it should always be inside a BSC.<br />
Several studies have demonstrated that the use <strong>of</strong> a CSTD in<br />
addition to a BSC reduces surface contamination <strong>of</strong> hazardous<br />
drugs in the workplace. Strong consideration should be made to<br />
using a CSTD for transferring hazardous drugs between containers<br />
whenever practicable.<br />
In the Regulation<br />
Locking fittings which<br />
cannot accidentally<br />
disconnect must be<br />
must be used where<br />
cytotoxic drugs<br />
are present. See<br />
section 6.54 <strong>of</strong> the<br />
Regulation.<br />
Additional equipment<br />
Many different types <strong>of</strong> equipment and supplies are used in the<br />
preparation <strong>of</strong> hazardous drugs. Further examples include:<br />
••<br />
Fittings that prevent accidental disconnection, such as luer lock<br />
fittings<br />
••<br />
Appropriate needleless systems or safety engineered needles<br />
that reduce the risk <strong>of</strong> workers getting a percutaneous exposure<br />
••<br />
Filtered venting devices, such as chemotherapy dispensing pins<br />
and chemotherapy vents, which can minimize the accidental<br />
release <strong>of</strong> hazardous drugs when reconstituting or withdrawing<br />
from a vial<br />
Refer to Appendix 6 for information on medical equipment that<br />
may be appropriate for use with hazardous drugs.<br />
Best Practices for the <strong>Safe</strong> <strong>Handling</strong> <strong>of</strong> <strong>Hazardous</strong> <strong>Drugs</strong> 35
In the Regulation<br />
<strong>Safe</strong>ty engineered<br />
needles or needleless<br />
systems must be<br />
used when caring<br />
for or treating a<br />
person. This applies<br />
to all hazardous<br />
drugs, including<br />
cytotoxic drugs. See<br />
section 6.36 <strong>of</strong> the<br />
Regulation.<br />
15.3 Guidelines for safe work practice<br />
Best practices for the preparation <strong>of</strong> hazardous drugs include:<br />
••<br />
Obtaining hazardous drugs from the supplier in a form that is<br />
ready to administer<br />
••<br />
Using safety-engineered needles that do not produce spray<br />
when activated<br />
••<br />
Using CSTDs<br />
••<br />
Using disposable plastic syringes<br />
••<br />
Using an approved BSC for preparations <strong>of</strong> hazardous drugs<br />
(where possible, the BSC should be designated for either sterile<br />
or non-sterile compounding)<br />
••<br />
Planning tasks to avoid unnecessary leaving and re-entering the<br />
preparation room<br />
••<br />
Limiting access to the preparation room to workers trained to<br />
work in the room (such as pharmacy and housekeeping staff)<br />
••<br />
Limiting equipment and materials in a BSC to those required to<br />
prepare one dose for one patient, to avoid overcrowding and<br />
mixing up drugs<br />
••<br />
Implementing procedures for priming equipment with a<br />
hazardous drug solution in a BSC (see the next chapter for<br />
priming with a non-hazardous drug solution)<br />
••<br />
Implementing procedures to have all alterations <strong>of</strong> hazardous<br />
drug tablets or capsules (such as cutting, splitting, and crushing)<br />
inside an approved BSC<br />
••<br />
Not using automated unit-dose packaging machines or<br />
automated counting machines with tablet or capsule forms <strong>of</strong><br />
hazardous drugs<br />
••<br />
Implementing procedures to reduce contamination <strong>of</strong> containers<br />
and IV bags after they leave the BSC, such as cleaning with a<br />
soap-moistened towel and placing the product in a clear<br />
resealable bag<br />
15.4 Cleaning<br />
The preparation room should also be cleaned regularly as part <strong>of</strong><br />
regular housekeeping and throughout the work day. This includes:<br />
••<br />
Regular cleaning <strong>of</strong> the interior <strong>of</strong> the BSC<br />
••<br />
Cleaning and decontaminating <strong>of</strong> the preparation room, from<br />
cleanest areas to the most contaminated (for example, from the<br />
walls and then inwards to the BSC)<br />
••<br />
Cleaning, disinfecting, and decontaminating the entire interior <strong>of</strong><br />
the cabinet after a non-sterile preparation (this should be done<br />
before a sterile preparation can be performed in the same BSC)<br />
36<br />
Best Practices for the <strong>Safe</strong> <strong>Handling</strong> <strong>of</strong> <strong>Hazardous</strong> <strong>Drugs</strong>
Refer to Appendix 7 for more information on the selection <strong>of</strong><br />
cleaning agents.<br />
In the Regulation<br />
PPE that is consistent<br />
with the ECP must be<br />
used where cytotoxic<br />
drugs are present.<br />
See section 6.55 <strong>of</strong><br />
the Regulation.<br />
15.5 Personal protective equipment (PPE)<br />
PPE must be consistent with the worker’s potential exposure and<br />
may include:<br />
••<br />
Chemotherapy-tested gloves<br />
••<br />
A chemotherapy-tested gown<br />
••<br />
Shoe covers<br />
••<br />
Eye and face protection<br />
••<br />
An approved and fit-tested respirator<br />
Refer to Appendix 4 for more details on PPE.<br />
Best Practices for the <strong>Safe</strong> <strong>Handling</strong> <strong>of</strong> <strong>Hazardous</strong> <strong>Drugs</strong> 37
16. Drug administration<br />
Administration <strong>of</strong> hazardous drugs can take many forms, such as IV<br />
therapy, inhalation therapy, surgical procedures, injections, oral,<br />
and topical medications.<br />
Potential activities that could result in exposure include:<br />
••<br />
Using administration equipment that may leak or spill, such as<br />
IV equipment<br />
••<br />
Cutting or crushing tablets at the point <strong>of</strong> administration<br />
••<br />
Directly handling medications, such as oral or topical treatments<br />
••<br />
Removing air or priming equipment such as syringes<br />
••<br />
Exposure to blood or body fluids during the precautionary<br />
period<br />
16.1 Work area design<br />
<strong>Hazardous</strong> drugs are administered in treatment areas in a number<br />
<strong>of</strong> different settings. The design <strong>of</strong> treatment areas should reflect<br />
the findings <strong>of</strong> the risk assessment.<br />
Treatment areas where hazardous drugs are administered:<br />
••<br />
Should be kept under neutral or negative air pressure to the<br />
surrounding rooms, where possible<br />
••<br />
Should use surfaces that are easy to clean, such as stainless steel,<br />
where possible<br />
••<br />
Should keep any rest areas for workers or visitors isolated from<br />
any administration areas<br />
In the Regulation<br />
All activities involving<br />
the administration<br />
<strong>of</strong> medication to<br />
a person must be<br />
done using a safety<br />
engineered medical<br />
sharp or a needleless<br />
system. See section<br />
6.36 <strong>of</strong> the Regulation.<br />
16.2 Drug administration equipment<br />
The selection <strong>of</strong> appropriate equipment for the administration <strong>of</strong><br />
hazardous drugs can help minimize the risk <strong>of</strong> exposure to workers.<br />
All activities involving the administration <strong>of</strong> medication to a person<br />
must be done with safety-engineered medical sharps or a<br />
needleless system, where clinically appropriate.<br />
Equipment used for the administration <strong>of</strong> hazardous drugs includes:<br />
••<br />
Closed-system transfer devices (CSTDs) designed for the<br />
administration <strong>of</strong> hazardous drugs<br />
••<br />
<strong>Safe</strong>ty-engineered needles<br />
38<br />
Best Practices for the <strong>Safe</strong> <strong>Handling</strong> <strong>of</strong> <strong>Hazardous</strong> <strong>Drugs</strong>
••<br />
Filtered venting devices, such as chemotherapy-dispensing pins<br />
and chemotherapy vents<br />
••<br />
Administration equipment, such as IV pumps and CADD pumps<br />
Refer to Appendix 6 for information on how to select medical<br />
equipment that is appropriate for use with hazardous drugs.<br />
16.3 Guidelines for safe work practice<br />
In the Regulation<br />
All priming <strong>of</strong><br />
administration sets<br />
with a cytotoxic drug<br />
must be performed<br />
in an approved BSC.<br />
See section 6.53 <strong>of</strong><br />
the Regulation<br />
Best practices for the administration <strong>of</strong> hazardous drugs include:<br />
••<br />
Avoiding priming IVs with a hazardous drug solution at the point<br />
<strong>of</strong> administration (this should be done as part <strong>of</strong> the preparation<br />
step in an approved BSC)<br />
••<br />
Avoiding altering oral medications, such as crushing or cutting, at<br />
the point <strong>of</strong> administration (this should be done as part <strong>of</strong> the<br />
preparation step in an approved BSC)<br />
••<br />
Where possible, avoiding contact with oral medications during<br />
administration by using medication cups, unit-dose packaging<br />
from the manufacturer, or having patients administer their own<br />
medication<br />
••<br />
If priming <strong>of</strong> administration sets cannot be done as part <strong>of</strong> the<br />
preparation step, implementing procedures so that priming is<br />
performed with compatible dilutant and the drug is added afterwards<br />
••<br />
Using CSTDs for administration activities, including withdrawing<br />
and injecting hazardous drugs from syringes and IV systems<br />
••<br />
Using disposable, absorbent pads to be placed under the patient<br />
where administration is occurring<br />
••<br />
Using bandages that can be applied over an area where a topical<br />
medication has been applied to avoid spreading contamination<br />
to clothing or bedsheets<br />
••<br />
Limiting access to administration areas (this is extremely important<br />
for some administration forms, particularly aerosolization therapy,<br />
and only the patient should be in the room where treatment is<br />
taking place)<br />
••<br />
Implementing procedures for proper disposal <strong>of</strong> administration<br />
equipment, such as flushing IV tubing with a dilutant before<br />
disconnecting or discarding tubing immediately after use as<br />
hazardous waste<br />
16.4 Cleaning<br />
There should be regular cleaning <strong>of</strong> administration areas. The<br />
administration area should have a set <strong>of</strong> cleaning equipment<br />
dedicated for that area.<br />
Best Practices for the <strong>Safe</strong> <strong>Handling</strong> <strong>of</strong> <strong>Hazardous</strong> <strong>Drugs</strong> 39
Work areas, such as trays, carts, tabletops, chairs, and beds where<br />
hazardous drugs are administered, should be cleaned daily.<br />
Refer to Appendix 7 for more information on the selection <strong>of</strong><br />
cleaning agents.<br />
16.5 Considerations for home care<br />
Administering hazardous drugs in home care settings poses<br />
additional challenges because there is less ability to change the<br />
physical work environment.<br />
Where possible, an initial assessment <strong>of</strong> the home should be done<br />
to determine that there are appropriate facilities for the activities<br />
that will take place in the home. This may include:<br />
••<br />
Running water to allow for hand washing<br />
••<br />
A properly functioning toilet<br />
••<br />
Windows that can be opened to provide ventilation<br />
The guidelines for safe work practice in administration settings<br />
discussed in the previous sections may also be applied in the home<br />
care setting, where relevant. Additional best practices for<br />
administration in the home include:<br />
••<br />
As much as possible, avoiding any alteration <strong>of</strong> hazardous drugs<br />
in the home (activities such as cutting or crushing oral<br />
medications and dissolving powders into solution should be<br />
done by pharmacy staff in a BSC)<br />
••<br />
Providing the patient with instructions on:<br />
––<br />
How to use administration equipment, such as electronic<br />
diffusion devices<br />
––<br />
<strong>Safe</strong> handling precautions for bodily fluids during the<br />
precautionary period for their treatment, including<br />
recommendations for the equipment and PPE required<br />
––<br />
How to safely dispose <strong>of</strong> hazardous drug waste and<br />
contaminated medical sharps<br />
The precautionary period is the period <strong>of</strong> time that a patient<br />
excretes hazardous drugs after their treatment. For most treatment<br />
protocols this is 48 hours but may be up to seven days. Refer to<br />
the treatment protocol to determine the precautionary period for<br />
each patient.<br />
40<br />
Best Practices for the <strong>Safe</strong> <strong>Handling</strong> <strong>of</strong> <strong>Hazardous</strong> <strong>Drugs</strong>
In the Regulation<br />
PPE that is consistent<br />
with the ECP must be<br />
used where cytotoxic<br />
drugs are present.<br />
See section 6.55 <strong>of</strong><br />
the Regulation.<br />
16.6 Personal protective equipment (PPE)<br />
PPE must be consistent with the worker’s potential exposure and<br />
may include:<br />
••<br />
Chemotherapy-tested gloves<br />
••<br />
A chemotherapy-tested gown<br />
••<br />
Face and eye protection<br />
Refer to Appendix 4 for more details on PPE.<br />
Best Practices for the <strong>Safe</strong> <strong>Handling</strong> <strong>of</strong> <strong>Hazardous</strong> <strong>Drugs</strong> 41
17. Veterinary practice<br />
In the Regulation<br />
To reduce exposure,<br />
appropriate<br />
treatment controls<br />
resulting from a risk<br />
assessment must<br />
be applied where<br />
cytotoxic drugs are<br />
present. See sections<br />
5.55 and 6.43 <strong>of</strong> the<br />
Regulation.<br />
<strong>Hazardous</strong> drugs are increasingly being used to treat animals,<br />
ranging from cats and dogs to horses. Regardless <strong>of</strong> whether the<br />
animal is being treated at a clinic or in the community (for example,<br />
a barn), there should be a risk assessment to determine appropriate<br />
controls for reducing worker exposure to hazardous drugs.<br />
Potential activities that could result in exposure include:<br />
••<br />
Administering hazardous drugs to animal patients<br />
••<br />
Holding the animal during treatment<br />
••<br />
Cleaning the treatment area, cages, or kennels<br />
17.1 Work area design<br />
In order to minimize exposure, veterinary settings where hazardous<br />
drugs are administered should have appropriate controls reflecting<br />
the results <strong>of</strong> the risk assessment. This may include:<br />
••<br />
Having a preparation room as described in Chapter 15 if any<br />
preparation activities take place at the facility<br />
••<br />
Having a separate storage area for hazardous drugs, away from<br />
other drugs and from animal or worker food and drink<br />
••<br />
Having one room dedicated for the administration <strong>of</strong> hazardous<br />
drugs<br />
••<br />
Having cages, kennels, or stalls dedicated for animals that are<br />
receiving or have recently received chemotherapy<br />
42<br />
Best Practices for the <strong>Safe</strong> <strong>Handling</strong> <strong>of</strong> <strong>Hazardous</strong> <strong>Drugs</strong>
In the Regulation<br />
Where preparation<br />
activities involving<br />
cytotoxic drugs take<br />
place at the facility, an<br />
approved BSC must<br />
be provided and used.<br />
See section 6.53 <strong>of</strong><br />
the Regulation.<br />
Where a BSC is used,<br />
it must be equipped<br />
with a continuous<br />
airflow monitoring<br />
device where<br />
cytotoxic drugs are<br />
present. See section<br />
6.53(1)(c) <strong>of</strong> the<br />
Regulation.<br />
17.2 Equipment<br />
Appropriate equipment for using hazardous drugs in veterinary<br />
practice may include:<br />
••<br />
An approved BSC, if any preparation activities take place at the<br />
facility.<br />
••<br />
<strong>Safe</strong>ty-engineered sharps or needleless systems for the<br />
administration <strong>of</strong> hazardous drugs. Although not a regulatory<br />
requirement in veterinary practice, these reduce the risk <strong>of</strong><br />
exposure to workers.<br />
••<br />
Equipment dedicated for use with animals receiving hazardous<br />
drugs.<br />
Refer to Appendix 6 for information on how to select equipment<br />
that is appropriate for use with hazardous drugs.<br />
17.3 Guidelines for safe work practice<br />
Best practices for the use <strong>of</strong> hazardous drugs in veterinary settings<br />
include:<br />
••<br />
Where possible, purchasing hazardous drugs in a form that is ready<br />
to administer, to avoid preparation activities at the practice facility<br />
••<br />
Where possible, referring animals to specialized treatment centres<br />
••<br />
Identifying animals who have received hazardous drugs, such as<br />
by placing signs on cages or kennels<br />
••<br />
Prohibiting the use <strong>of</strong> pressure washers to clean cages, kennels,<br />
and stalls <strong>of</strong> animals being treated with hazardous drugs to<br />
minimize the spread <strong>of</strong> aerosolized contamination<br />
••<br />
Supplying disposable towels for cleaning cages, kennels, and<br />
animals, where practicable<br />
Animals who have received hazardous drugs should also be cared<br />
for with safe handling precautions after their treatment (see Chapter<br />
18, “Patient Care”).<br />
17.4 Cleaning<br />
Cleaning and decontamination <strong>of</strong> the veterinary practice facility<br />
should take place regularly to reduce contamination with hazardous<br />
drug residues. This includes:<br />
••<br />
Regular cleaning <strong>of</strong> animal excreta<br />
••<br />
Regular cleaning and decontamination <strong>of</strong> the treatment area<br />
••<br />
Gently hosing down cages and kennels to avoid producing<br />
aerosolized contamination<br />
Best Practices for the <strong>Safe</strong> <strong>Handling</strong> <strong>of</strong> <strong>Hazardous</strong> <strong>Drugs</strong> 43
In the Regulation<br />
PPE that is consistent<br />
with the ECP must be<br />
used where cytotoxic<br />
drugs are present.<br />
See section 6.55 <strong>of</strong><br />
the Regulation.<br />
17.5 Personal protective equipment (PPE)<br />
PPE must be consistent with the worker’s potential exposure and<br />
may include:<br />
••<br />
Chemotherapy-tested gloves<br />
••<br />
A chemotherapy-tested gown<br />
••<br />
Face and eye protection<br />
••<br />
An approved and fit-tested respirator<br />
Refer to Appendix 4 for more details on PPE.<br />
44<br />
Best Practices for the <strong>Safe</strong> <strong>Handling</strong> <strong>of</strong> <strong>Hazardous</strong> <strong>Drugs</strong>
18. Patient care<br />
Providing personal care for patients receiving hazardous drugs<br />
requires additional precautions. Body fluids have been shown to<br />
contain hazardous drugs for a set amount <strong>of</strong> time known as the<br />
precautionary period, which is the period <strong>of</strong> time that safe handling<br />
precautions are required when caring for the patient.<br />
Potential activities that could result in exposure include:<br />
••<br />
<strong>Handling</strong> patient bodily fluids from a patient who has received<br />
hazardous drugs<br />
••<br />
Bathing the patient<br />
••<br />
<strong>Handling</strong> contaminated bedding or laundry<br />
••<br />
Assisting with toileting, especially flushing toilets<br />
••<br />
Cleaning the patient’s room, washroom, or home<br />
18.1 Work area design<br />
The design <strong>of</strong> the patient care area must reflect the results <strong>of</strong> a risk<br />
assessment to reduce exposure to hazardous drugs.<br />
In general, care areas where patients are receiving or have received<br />
hazardous drugs should:<br />
••<br />
Be isolated from other patient care areas, where possible<br />
••<br />
Have dedicated washroom facilities for patients who have<br />
received hazardous drugs<br />
••<br />
Have appropriate laundry services<br />
18.2 Equipment<br />
Equipment used for caring for patients within the precautionary<br />
period includes:<br />
••<br />
Bed pans that are disposable, when possible<br />
••<br />
Carts and trays that are easy to clean and dedicated for use with<br />
patients who have received hazardous drugs<br />
Refer to Appendix 6 for information on how to select medical<br />
equipment that is appropriate for use with hazardous drugs.<br />
Best Practices for the <strong>Safe</strong> <strong>Handling</strong> <strong>of</strong> <strong>Hazardous</strong> <strong>Drugs</strong> 45
In the Regulation<br />
Employers must have<br />
procedures for the<br />
disposal <strong>of</strong> body<br />
fluids from patients<br />
who have been treated<br />
with cytotoxic drugs.<br />
See sections 6.48 and<br />
6.57 <strong>of</strong> the Regulation.<br />
18.3 Guidelines for safe work practice<br />
Best practices for the care <strong>of</strong> patients receiving or who have<br />
received hazardous drugs include:<br />
••<br />
Implementing safe handling procedures for handling body fluids<br />
<strong>of</strong> patients within the precautionary period, such as covering<br />
toilets and double flushing<br />
••<br />
Implementing safe handling procedures for handling laundry<br />
from patients within the precautionary period, such as avoiding<br />
shaking, folding the bedding so any contamination is trapped in<br />
the centre, and placing laundry in a plastic bag<br />
••<br />
Where possible, discarding laundry or bedding that is heavily<br />
contaminated by body fluids, or alternatively washing separately<br />
once before being added to other facility laundry<br />
••<br />
On top <strong>of</strong> regular charting requirements, documenting the length<br />
<strong>of</strong> the precautionary period for the patient as per the treatment<br />
protocol<br />
••<br />
Ensuring workers review patient history before providing care<br />
When patients are being cared for after treatment at home, either<br />
by a health care worker or their family, they should be provided<br />
with the instructions described in Chapter 15.<br />
18.4 Cleaning<br />
Patient care areas should be cleaned and decontaminated regularly.<br />
This includes:<br />
••<br />
Cleaning washrooms <strong>of</strong> patients receiving hazardous drugs regularly<br />
••<br />
Cleaning up spills <strong>of</strong> patient body fluids immediately<br />
In the Regulation<br />
PPE that is consistent<br />
with the ECP must be<br />
used where cytotoxic<br />
drugs are present.<br />
See section 6.55 <strong>of</strong><br />
the Regulation.<br />
18.5 Personal protective equipment (PPE)<br />
PPE must be consistent with the worker’s potential exposure and<br />
may include:<br />
••<br />
Chemotherapy-tested gloves<br />
••<br />
A chemotherapy-tested gown, if there is a risk <strong>of</strong> splashing <strong>of</strong><br />
body fluids<br />
••<br />
Face and eye protection, if there is a risk <strong>of</strong> splashing <strong>of</strong> body fluids<br />
••<br />
An approved and fit-tested respirator, if there is a risk <strong>of</strong> inhaling<br />
aerosols or particulates<br />
Refer to Appendix 4 for more details on PPE.<br />
46<br />
Best Practices for the <strong>Safe</strong> <strong>Handling</strong> <strong>of</strong> <strong>Hazardous</strong> <strong>Drugs</strong>
19. Cleaning<br />
Many workplaces may have contract workers who are responsible<br />
for the majority <strong>of</strong> cleaning activities. If this is the case, it is<br />
essential that there is coordination with the contracting company to<br />
develop procedures to minimize hazardous drug contamination<br />
throughout the workplace.<br />
Potential activities that could result in exposure include:<br />
••<br />
Contact with hazardous drug surface contamination<br />
••<br />
Contact with body fluids or waste<br />
••<br />
Splashing <strong>of</strong> cleaning solutions used to clean hazardous drugs<br />
19.1 Guidelines for safe work practice<br />
Best practices for cleaning activities in areas with hazardous drug<br />
contamination include:<br />
••<br />
Providing training on hazardous drugs for workers, including<br />
potential routes <strong>of</strong> exposure and how to minimize exposure for<br />
themselves<br />
••<br />
Using cleaning supplies designated for areas known to have<br />
potentially high hazardous drug contamination, such as<br />
pharmacies<br />
••<br />
Changing routine cleaning practices to minimize hazardous drug<br />
contamination<br />
Refer to Appendix 7 for information on how to select appropriate<br />
cleaning agents for use with hazardous drugs.<br />
In the Regulation<br />
PPE that is consistent<br />
with the ECP must be<br />
used where cytotoxic<br />
drugs are present.<br />
See section 6.55 <strong>of</strong><br />
the Regulation.<br />
19.2 Personal protective equipment (PPE)<br />
PPE must be consistent with the worker’s potential exposure and<br />
may include:<br />
••<br />
Chemotherapy-tested gloves<br />
••<br />
A chemotherapy-tested gown<br />
••<br />
Face and eye protection,<br />
••<br />
An approved and fit-tested respirator<br />
Refer to Appendix 4 for more details on PPE.<br />
Best Practices for the <strong>Safe</strong> <strong>Handling</strong> <strong>of</strong> <strong>Hazardous</strong> <strong>Drugs</strong> 47
20. Waste disposal<br />
In the Regulation<br />
The employer must<br />
develop safe work<br />
procedures for<br />
handling cytotoxic<br />
drug waste. See<br />
sections 6.48<br />
and 6.57 <strong>of</strong> the<br />
Regulation.<br />
<strong>Hazardous</strong> drug waste is a potential source <strong>of</strong> exposure to<br />
hazardous drugs. The employer should develop safe work<br />
procedures for safely disposing <strong>of</strong> hazardous drug waste.<br />
<strong>Hazardous</strong> drug waste may include:<br />
••<br />
<strong>Hazardous</strong> drugs that are to be disposed <strong>of</strong><br />
••<br />
Disposable equipment used to administer hazardous drugs, such<br />
as syringes, needles, or IV tubing<br />
••<br />
Disposable PPE used for protection against exposure to<br />
hazardous drugs<br />
••<br />
Bodily fluids, such as vomit, stool, urine, and sweat, from<br />
patients who have recently received hazardous drugs<br />
••<br />
Disposable materials contaminated with body fluids from<br />
patients who are within the precautionary period<br />
Potential activities that could result in exposure include:<br />
••<br />
Disposing <strong>of</strong> hazardous drug-related waste, if it is contaminated<br />
or leaking<br />
••<br />
<strong>Handling</strong> hazardous drug waste containers, which may have<br />
surface contamination<br />
20.1 Work area design<br />
If hazardous drug waste is stored at the workplace before it is taken<br />
to be disposed <strong>of</strong>, it should be stored with appropriate precautions,<br />
as determined by the risk assessment. This includes:<br />
••<br />
Storing hazardous drug waste in a cool, locked, and ventilated<br />
area until it is transported out <strong>of</strong> the facility<br />
••<br />
Isolating the storage area for hazardous drug waste from other<br />
areas <strong>of</strong> the workplace as much as possible<br />
••<br />
Storing in a manner to prevent leaks and spills, such as by having<br />
shelves with lipped edges<br />
••<br />
Using materials that are easy to clean, such as stainless steel<br />
48<br />
Best Practices for the <strong>Safe</strong> <strong>Handling</strong> <strong>of</strong> <strong>Hazardous</strong> <strong>Drugs</strong>
In the Regulation<br />
A hazardous drug<br />
waste container or<br />
bag must be provided<br />
where cytotoxic<br />
drugs are present.<br />
See section 6.57 <strong>of</strong><br />
the Regulation.<br />
20.2 Equipment<br />
<strong>Hazardous</strong> drug waste should be collected in a hazardous drug<br />
waste container.<br />
A hazardous drug waste container:<br />
••<br />
Must be leak-pro<strong>of</strong> and puncture resistant<br />
••<br />
Must be designated for use with hazardous drugs<br />
••<br />
Should be easily identifiable as designated for hazardous drugs,<br />
such as by using a uniform colour throughout the workplace<br />
A bag used for disposal <strong>of</strong> s<strong>of</strong>t materials (for example, laundry,<br />
gloves, or gowns) contaminated with hazardous drugs:<br />
••<br />
Should be leak-pro<strong>of</strong><br />
••<br />
Should be made <strong>of</strong> thick, leak-pro<strong>of</strong> plastic<br />
••<br />
Should be easily identifiable<br />
••<br />
Must be appropriately labelled with a hazardous drug warning<br />
All areas where there is potential for hazardous drug waste should<br />
have a hazardous drug waste container. These areas can be<br />
determined as part <strong>of</strong> a risk assessment.<br />
<strong>Hazardous</strong> drug waste containers and bags should also be provided<br />
to patients and animal owners who are receiving hazardous drugs<br />
or being cared for at home.<br />
20.3 Guidelines for safe work practice<br />
For information on<br />
hazardous waste<br />
disposal in B.C., visit<br />
www.hazwastebc.com.<br />
Best practices for disposal <strong>of</strong> hazardous drug waste include:<br />
••<br />
Coordinating <strong>of</strong> hazardous drug communication with external<br />
waste-collection companies to reduce worker exposure<br />
••<br />
Sending hazardous drug waste for disposal by a certified<br />
hazardous waste organization and in accordance with local<br />
regulations<br />
••<br />
Having hazardous drug waste containers collected and<br />
transported throughout a facility only by workers trained to do so<br />
••<br />
Arranging for the collection <strong>of</strong> hazardous drug waste containers<br />
from patients homes<br />
••<br />
Implementing procedures to reduce leaks from hazardous waste<br />
containers, such as by placing contaminated items in double<br />
plastic bags before placing in a hazardous drug waste container<br />
Refer to CSA Standard Z317.10-09 <strong>Handling</strong> <strong>of</strong> Waste Materials in<br />
Health Care Facilities and Veterinary Health Care Facilities for<br />
more information on hazardous drug waste.<br />
Best Practices for the <strong>Safe</strong> <strong>Handling</strong> <strong>of</strong> <strong>Hazardous</strong> <strong>Drugs</strong> 49
In the Regulation<br />
PPE that is consistent<br />
with the ECP must be<br />
used where cytotoxic<br />
drugs are present.<br />
See section 6.55 <strong>of</strong><br />
the Regulation.<br />
20.4 Personal protective equipment (PPE)<br />
PPE must be consistent with the worker’s potential exposure and<br />
may include:<br />
••<br />
Chemotherapy-tested gloves<br />
••<br />
A chemotherapy-tested gown<br />
••<br />
Face and eye protection, if there is a risk <strong>of</strong> splashing<br />
••<br />
An approved and fit-tested respirator if there is a risk <strong>of</strong> inhaling<br />
aerosols or particulate<br />
Refer to Appendix 4 for more details on PPE.<br />
50<br />
Best Practices for the <strong>Safe</strong> <strong>Handling</strong> <strong>of</strong> <strong>Hazardous</strong> <strong>Drugs</strong>
21. Spill response<br />
In the Regulation<br />
Employers must<br />
develop emergency<br />
procedures for spills<br />
<strong>of</strong> cytotoxic drugs.<br />
See section 6.58(1) <strong>of</strong><br />
the Regulation.<br />
Employers must develop emergency procedures that address spills<br />
<strong>of</strong> hazardous drugs. Signs detailing spill response procedures<br />
should be posted in all relevant areas <strong>of</strong> the workplace.<br />
Potential activities that could result in exposure include:<br />
••<br />
Contact with a leak or spill<br />
••<br />
Inhalation <strong>of</strong> aerosols, vapours, or particulates released as the<br />
result <strong>of</strong> a spill<br />
••<br />
Contact with contaminated cleaning supplies<br />
In the Regulation<br />
Spill kits must be<br />
provided where<br />
cytotoxic drugs<br />
are present. See<br />
section 6.58(2) <strong>of</strong> the<br />
Regulation.<br />
21.1 Guidelines for safe work practice<br />
Best practices for hazardous drug spill response include:<br />
••<br />
Supplying a spill kit in all areas where hazardous drugs are<br />
handled<br />
••<br />
Placing personnel decontamination kits in all areas where<br />
hazardous drugs are handled<br />
••<br />
Providing home care workers who are administering hazardous<br />
drugs with the tools they might need to safely clean up a spill<br />
••<br />
Providing regular training on emergency spill procedures<br />
••<br />
Allowing only workers trained and authorized to clean spills to do so<br />
••<br />
Training workers not authorized to clean a large spill on how to<br />
notify other workers and block <strong>of</strong>f an area<br />
••<br />
Ensuring all spill cleanup supplies are discarded as hazardous waste<br />
Refer to Appendix 8 for an example <strong>of</strong> what should be included in a<br />
spill kit.<br />
In the Regulation<br />
PPE that is consistent<br />
with the ECP must be<br />
used where cytotoxic<br />
drugs are present.<br />
See section 6.55 <strong>of</strong><br />
the Regulation.<br />
21.2 Personal protective equipment (PPE)<br />
PPE must be consistent with the worker’s potential exposure and<br />
may include:<br />
••<br />
Chemotherapy-tested gloves<br />
••<br />
A chemotherapy-tested gown<br />
••<br />
Face and eye protection, if there is a risk <strong>of</strong> splashing<br />
••<br />
An approved and fit-tested respirator, if there is a risk <strong>of</strong> inhaling<br />
aerosols or particulate<br />
Refer to Appendix 4 for more details on PPE.<br />
Best Practices for the <strong>Safe</strong> <strong>Handling</strong> <strong>of</strong> <strong>Hazardous</strong> <strong>Drugs</strong> 51
Appendices
Appendix 1: References and resources<br />
Health effects <strong>of</strong> occupational exposure<br />
Connor, T.H, Lawson, C.C, Polovich, M, McDiarmid, M.A.<br />
Reproductive health risks associated with occupational exposures<br />
to antineoplastic drugs in health care settings — A review <strong>of</strong> the<br />
evidence. J Occup Environ Med 56 (2014):901-910.<br />
Fransman, W., Kager, H., Meijster, T., Heederick, D., Kromhout, H.,<br />
Portengen, L., Blaauboer, BJ. Leukemia from dermal exposure to<br />
cyclophosphamide among nurses in the netherlands: Quantitative<br />
assessment <strong>of</strong> the risk. Ann Occup Hyg (2014): 1-12. doi:10.1093/<br />
annhyg/met077.<br />
Hemminki K, Kyyrönen P, Lindbohm M-L. Spontaneous abortions<br />
and malformations in the <strong>of</strong>fspring <strong>of</strong> nurses exposed to anesthetic<br />
gases, cytostatic drugs, and other potential hazards in hospitals,<br />
based on registered information <strong>of</strong> outcome. J Epidemol<br />
Community Health 39 (1985): 141-147.<br />
Hon, C., Teschke, K., Shen, H., Demers, PA., Venners, S.<br />
Antineoplastic drug contamination in the urine <strong>of</strong> Canadian<br />
healthcare workers. Int Arch Occup Environ Health (2015) DOI<br />
10.1007/s00420-015-1026-1.<br />
Ratner, PA., Spinelli, JJ., Beking, K., Lorenzi, M., Chow, Y., Teschke,<br />
K., Le, ND., Gallagher, RP., Dimich-Ward, H. Cancer incidence and<br />
adverse pregnancy outcome in registered nurses potentially<br />
exposed to antineoplastic drugs. BMC Nurs 9:15 (2010).<br />
Selevan SG, Lindbohm ML, Hornung RW, Hemminki K. A study <strong>of</strong><br />
occupational exposure to antineoplastic drugs and fetal loss in<br />
nurses. N Engl J Med 313 (1985): 1173–78.<br />
Sessink PJM, Cerna M, Rossner P, Pastorkova A, Bavarova H,<br />
Frankova K, Anzion RB, Bos RP. Urinary cyclophosphamide<br />
excretion and chromosomal aberrations in peripheral blood<br />
lymphocytes after occupational exposure to antineoplastic agents.<br />
Mutat Res 309.2 (1994): 193-199.<br />
Stücker I, Caliiard J-F, Collin R, Gout M, Poyen D, Hémon, D. Risk<br />
<strong>of</strong> spontaneous abortion among nurses handling antineoplastic<br />
drugs. Scand J Work Environ Health 16 (1990): 102–107.<br />
Best Practices for the <strong>Safe</strong> <strong>Handling</strong> <strong>of</strong> <strong>Hazardous</strong> <strong>Drugs</strong> 55
Valanis B, Vollmer WM, Steele P. Occupational exposure to<br />
antineoplastic agents: Self-reported miscarriages and stillbirths among<br />
nurses and pharmacists. J Occup Environ Med 41 (1999): 632–638.<br />
Routes <strong>of</strong> occupational exposure<br />
Connor T.H. Permeability <strong>of</strong> nitrile rubber, latex, polyurethane, and<br />
neoprene gloves to 18 antineoplastic drugs. Am J Health Syst<br />
Pharm 56.23 (1999): 2450-2453.<br />
Connor T.H, DeBord, D.G, Pretty, J.R, Oliver, M.S, Roth, T.S, Lees,<br />
P.S.J, Krieg, E.F. Evaluation <strong>of</strong> antineoplastic drug exposure <strong>of</strong><br />
health care workers at three university-based US cancer centers.<br />
American C Occ Env Med 52.10 (2010):1019-1027.<br />
Connor T.H, Shults, M, Fraser, M. Determination <strong>of</strong> the vaporization<br />
<strong>of</strong> solutions <strong>of</strong> mutagenic antineoplastic agents at 23 and 37˚C<br />
using a desiccators technique. Mutat Res 470 (2000): 85-92.<br />
Odraska, P., Mazaurova, E., Dolezalova, L., Blaha, L. In vitro evaluation<br />
<strong>of</strong> the permeation <strong>of</strong> cytotoxic drugs through reconstructed human<br />
epidermis and oral epithelium. Klin Onkol 24.3 (2011): 195-202.<br />
Turci R, Minoia C, Sottani C, Coghi R, Severi P, Castriotta C, et al.<br />
Occupational exposure to antineoplastic drugs in seven Italian<br />
hospitals: The effect <strong>of</strong> quality assurance and adherence to<br />
guidelines. J Oncol Pharm Pract. 17.4 (2011): 320-332.<br />
Surface contamination<br />
Connor T.H., Sessink P.J., Harrison B.R., Pretty J.R., Peters B.G.,<br />
Alfaro R.M., Bilos A., Beckmann G., Bing M.R., Anderson L.M.,<br />
Dechrist<strong>of</strong>oro R. Surface contamination <strong>of</strong> chemotherapy drug vials<br />
and evaluation <strong>of</strong> new vial-cleaning techniques: results <strong>of</strong> three<br />
studies. Am J Health Syst Pharm 62.5 (2005):475-84.<br />
Hedmer M, Tinnerberg H, Axmon A, Joensson BAG. Environmental<br />
and biological monitoring <strong>of</strong> antineoplastic drugs in four<br />
workplaces in a Swedish hospital. Int Arch Occup Environ Health<br />
81.7 (2008): 899–911.<br />
Hon, C., Teschke, K., Chu, W., Demers, P., & Venners, S.<br />
Antineoplastic drug contamination <strong>of</strong> surfaces throughout the<br />
hospital medication system in canadian hospitals. J Occ Env Hyg<br />
10.7 (2013): 374-383 DOI: 10:1080/15459624.2013.789743.<br />
56<br />
Best Practices for the <strong>Safe</strong> <strong>Handling</strong> <strong>of</strong> <strong>Hazardous</strong> <strong>Drugs</strong>
Hon, C., Venners, S., Demers, P., Chua, P., Astrakianakis, G., Chu,<br />
W., Ensom, R., & Teschke, K. Healthcare workers and antineoplastic<br />
drugs: Identifying the determinants <strong>of</strong> exposure and current<br />
challenges to reducing exposure. (2012). Focus on Tomorrow.<br />
Closed-system transfer devices<br />
Sessink PJM, Trahan J and Coyne JW. Reduction in surface<br />
contamination with cyclophosphamide in 30 hospital pharmacies<br />
following implementation <strong>of</strong> a closed-system drug transfer device.<br />
Hosp Pharm 48 (2013):204-212.<br />
Yoshida J, Tei G, Mochizuki C, Masu Y, Koda S and Kumagai S. Use<br />
<strong>of</strong> a closed system device to reduce occupational contamination<br />
and exposure to antineoplastic drugs in the hospital work<br />
environment. Ann Occup Hyg 53 (2009):153-160.<br />
Cleaning and decontamination<br />
Barzan, C. Towards the Reduction <strong>of</strong> Occupational Exposure to<br />
Cytotoxic <strong>Drugs</strong>, 2010. Thesis dissertation.<br />
Lamerie, T.Q, Nussbaumer, S, Décaudin, B, Fleury-Souverain, S,<br />
Goossens, J.F, Bonnabry, P, Odou, P. Evaluation <strong>of</strong> decontamination<br />
efficacy <strong>of</strong> cleaning solutions on stainless steel and glass surfaces<br />
contaminated by 10 antineoplastic agents. Ann Occup Hyg 57.4<br />
(2013):456-469. DOI: 10.1093/annhyg/mes087.<br />
Best practice resources<br />
These resources were reviewed to develop the best practices<br />
throughout this book.<br />
American Society <strong>of</strong> Health System Pharmacists (ASHP). 2004.<br />
Guidelines on <strong>Handling</strong> <strong>Hazardous</strong> <strong>Drugs</strong>.<br />
Association paritaire pour la santé et la sécurité du travail du<br />
secteur affaires socials (ASSTSAS) [Joint Sector-based Association<br />
for Health and Occupational <strong>Safe</strong>ty for the Social Sector]. 2007.<br />
Prevention Guide: <strong>Safe</strong> <strong>Handling</strong> <strong>of</strong> <strong>Hazardous</strong> <strong>Drugs</strong>.<br />
BC Cancer Agency (BCCA). 2012. <strong>Safe</strong> <strong>Handling</strong> <strong>of</strong> <strong>Hazardous</strong><br />
<strong>Drugs</strong>- Module 1.<br />
Canadian Association <strong>of</strong> Pharmacy in Oncology (CAPhO). 2009.<br />
Standards <strong>of</strong> Practice for Oncology Practice in Canada.<br />
Best Practices for the <strong>Safe</strong> <strong>Handling</strong> <strong>of</strong> <strong>Hazardous</strong> <strong>Drugs</strong> 57
Chaffee, B, Armitstead, J, Benjamin, B, Cotugno, M, Forrey, R,<br />
Hintzen, B, Pfeiffenberger, T, & Stevenson, J. Guidelines for the<br />
safe handling <strong>of</strong> hazardous drugs: Consensus recommendations.<br />
Am J Health-Syst Pharm 67 (2010): 1254-1546.<br />
International Society <strong>of</strong> Oncology Pharmacy Practitioners (ISOPP).<br />
2007. Standards <strong>of</strong> Practice – <strong>Safe</strong> <strong>Handling</strong> <strong>of</strong> Cytotoxics.<br />
National Institute for Occupational <strong>Safe</strong>ty and Health (NIOSH). 2014.<br />
NIOSH List <strong>of</strong> Antineoplastic and Other <strong>Hazardous</strong> <strong>Drugs</strong> in<br />
Healthcare Settings, 2014. Centers for Disease Control and<br />
Prevention.<br />
National Institute for Occupational <strong>Safe</strong>ty and Health (NIOSH).<br />
2010. <strong>Safe</strong> <strong>Handling</strong> <strong>of</strong> <strong>Hazardous</strong> <strong>Drugs</strong> for Veterinary Workers.<br />
Workplace Solutions.<br />
National Institute for Occupational <strong>Safe</strong>ty and Health (NIOSH).<br />
2004. Preventing Occupational Exposures to Antineoplastics and<br />
Other <strong>Hazardous</strong> <strong>Drugs</strong> in Health Care Settings. NIOSH Alert.<br />
Occupational Health and <strong>Safe</strong>ty Administration (OSHA). 1999.<br />
Technical Manual Section VI Chapter 2– Controlling Occupational<br />
Exposure to <strong>Hazardous</strong> <strong>Drugs</strong>.<br />
Work<strong>Safe</strong> Victoria. 2013. <strong>Handling</strong> cytotoxic drugs in the<br />
workplace: <strong>Handling</strong> health and safety risks associated with<br />
handling cytotoxic drugs in the healthcare industry.<br />
In-text resources<br />
These are additional resources that are mentioned throughout the<br />
book.<br />
ASTM D6978 – 05(2013). American Society for Testing and<br />
Materials: Standard Practice for Assessment <strong>of</strong> Resistance <strong>of</strong><br />
Medical Gloves to Permeation by Chemotherapy Gloves.<br />
Canadian Biosafety Standards and Guidelines (CBSG) First Edition:<br />
http://canadianbiosafetystandards.collaboration.gc.ca/cbsg-nldcb/<br />
index-eng.php.<br />
Canadian Pharmacists Association (CPhA): Compendium <strong>of</strong><br />
Pharmaceuticals and Specialties (CPS).<br />
Canadian Standards Association (CSA): Z317.10-09 <strong>Handling</strong> <strong>of</strong><br />
Waste Materials in Health Care Facilities and Veterinary Health<br />
Care Facilities.<br />
58<br />
Best Practices for the <strong>Safe</strong> <strong>Handling</strong> <strong>of</strong> <strong>Hazardous</strong> <strong>Drugs</strong>
NIOSH: <strong>Hazardous</strong> <strong>Drugs</strong> webpage http://www/cdc/gov/niosh/<br />
docket/archive/docket233.html.<br />
NIOSH: Antineoplastic and <strong>Hazardous</strong> <strong>Drugs</strong> List http://www.cdc.<br />
gov/niosh/topics/hazdrug/#a.<br />
Health Canada: Drug Product Database http://www.hc-sc.gc.ca/<br />
dhp-mps/prodpharma/databasdon/index-eng.php.<br />
National Association <strong>of</strong> Pharmacy Regulatory Authorities (NAPRA):<br />
Model Standards for Pharmacy Compounding <strong>of</strong> <strong>Hazardous</strong> Sterile<br />
Products.<br />
United States Pharmacopeia (USP): Chapter Pharmaceutical<br />
Compounding – Nonsterile Preparations.<br />
United States Pharmacopeia (USP): Chapter Pharmaceutical<br />
Compounding – Sterile Preparations.<br />
United States Pharmacopeia (USP): Chapter <strong>Hazardous</strong><br />
<strong>Drugs</strong> – <strong>Handling</strong> in Healthcare Settings (Draft).<br />
Work<strong>Safe</strong>BC: Breathe <strong>Safe</strong>r: How to Use Respirators <strong>Safe</strong>ly and<br />
Start a Respirator Program http://www.worksafebc.com/<br />
publications/high_resolution_publications/assets/pdf/bk75.pdf.<br />
Work<strong>Safe</strong>BC: How to Implement a Formal Occupational Health<br />
and <strong>Safe</strong>ty Program http://www.worksafebc.com/publications/<br />
health_and_safety/by_topic/assets/pdf/howtoimplement_ohs.pdf.<br />
Best Practices for the <strong>Safe</strong> <strong>Handling</strong> <strong>of</strong> <strong>Hazardous</strong> <strong>Drugs</strong> 59
Appendix 2: Glossary<br />
Administrative<br />
controls<br />
Antineoplastic<br />
Biological safety<br />
cabinet (BSC)<br />
Biomarkers<br />
Chemical<br />
cartridge<br />
Chemotherapy<br />
gloves<br />
Clean room<br />
Closed-system<br />
transfer device<br />
(CSTD)<br />
Controls<br />
Cytotoxic drugs<br />
Engineering<br />
controls<br />
Methods that reduce exposure to a hazardous substance by changing work<br />
procedures and the organization <strong>of</strong> the workplace.<br />
An agent that acts to prevent, inhibit, or prevent the development <strong>of</strong> a<br />
neoplasm (a tumour), and which is most <strong>of</strong>ten used in the treatment <strong>of</strong><br />
cancer.<br />
A ventilated containment cabinet that provides an ISO Class 5 environment<br />
for compounding products.<br />
Measureable, biological signs that indicate exposure to a substance or<br />
development <strong>of</strong> a disease. For example, this could be a metabolite <strong>of</strong> a<br />
chemical or a predicted change in normal body functioning.<br />
A cartridge that can be added to an elastomeric respirator that is designed<br />
to trap gases or vapours from the air a worker breathes. These cartridges<br />
contain chemical compounds that react with specific contaminants so they<br />
are removed from the air and must be replaced following a specific<br />
schedule outlined by the manufacturer.<br />
Gloves that are designed specifically for handling hazardous drugs. They<br />
should be tested and approved according to the American Society for<br />
Testing and Materials (ASTM) standard for permeability to hazardous drugs.<br />
A preparation room where sterile drugs are prepared. It is “clean” because<br />
it controls the level <strong>of</strong> contamination by using ventilation and air flow to<br />
remove non-sterile air.<br />
A device that completely contains a substance it is carrying, by preventing<br />
leaks, airborne particulates, and vapours from escaping.<br />
Methods <strong>of</strong> protecting against hazards. In the case <strong>of</strong> hazardous drugs,<br />
they remove or minimize the risk <strong>of</strong> exposure to workers.<br />
<strong>Drugs</strong> that act to treat disease by killing cells. They are a subset <strong>of</strong><br />
hazardous drugs and are specifically covered under the Regulation.<br />
See the “About this Book” section for a detailed definition.<br />
Methods <strong>of</strong> minimizing exposure by physically changing the work<br />
environment to contain the source <strong>of</strong> exposure.<br />
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Environmental<br />
monitoring<br />
Exposure<br />
control plan<br />
Food and<br />
<strong>Drugs</strong> Act<br />
Genotoxic<br />
<strong>Hazardous</strong><br />
drugs<br />
<strong>Hazardous</strong><br />
waste container<br />
High efficiency<br />
particulate air<br />
(HEPA)<br />
ISO Class 7<br />
Luer lock<br />
Mutagenic<br />
Oncogenic<br />
The use <strong>of</strong> analytic techniques to measure contamination <strong>of</strong> an<br />
environment over a period <strong>of</strong> time. In the case <strong>of</strong> hazardous drugs, this is<br />
useful for identifying areas with higher amounts <strong>of</strong> contamination and<br />
determining whether current or introduced controls are effective at<br />
reducing the levels <strong>of</strong> hazardous drugs in the work environment.<br />
A requirement in the Regulation that details how the workplace will<br />
minimize exposure to hazardous drugs. Employers must develop and<br />
implement an exposure control plan if their workers may be exposed to<br />
cytotoxic drugs.<br />
Canadian federal legislation that regulates the use <strong>of</strong> cosmetics, drugs, and<br />
food. Substances under this act are not required to provide supplier labels<br />
and SDSs as described in WHMIS.<br />
A substance that can damage the genetic material <strong>of</strong> cells, which causes<br />
mutations to arise.<br />
As defined by NIOSH, a group <strong>of</strong> drugs that have know carcinogenicity,<br />
teratogenicity, reproductive toxicity, organ toxicity, or genotoxicity in<br />
humans or animals (or a new drug that mimics an existing drug with one <strong>of</strong><br />
these characteristics). Examples include drugs used for treatment <strong>of</strong><br />
cancer, hormone treatments, and diluted forms <strong>of</strong> these drugs used to<br />
treat a range <strong>of</strong> illnesses.<br />
A container that is designated to be used only for hazardous waste. These<br />
must be clearly labelled as meant for hazardous waste and are generally a<br />
different colour than other waste containers in the workplace so that they<br />
can be easily identified.<br />
A specialized filter that traps particulate matter. They are used to filter air<br />
that is entering a biological safety cabinet as well as air that is exhausted<br />
externally. They may also be used in local ventilation systems for specific<br />
rooms in a workplace.<br />
A measure <strong>of</strong> air quality using the ISO classification system, which is based<br />
on how much particulate is present per cubic metre <strong>of</strong> air. The classes go<br />
from what is considered the “dirtiest” air (ISO Class 9) to what is the<br />
“cleanest” air (ISO Class 1).<br />
A fitting for medical instruments that is designed to prevent leaking.<br />
A substance that causes mutations to occur in the genetic material <strong>of</strong> cells.<br />
Describes a substance that has the ability to cause a (malignant) cancer.<br />
Best Practices for the <strong>Safe</strong> <strong>Handling</strong> <strong>of</strong> <strong>Hazardous</strong> <strong>Drugs</strong> 61
Percutaneous<br />
Personal protective<br />
equipment (PPE)<br />
Permeability<br />
Precautionary<br />
period<br />
Priming<br />
Protective<br />
reassignment<br />
Risk assessment<br />
<strong>Safe</strong>ty-engineered<br />
medical sharp<br />
Substitution<br />
Surface<br />
contamination<br />
Surface wipe<br />
sampling<br />
A cut or puncture that breaks through the skin.<br />
A method <strong>of</strong> reducing occupational exposure to hazardous substances that<br />
involves the worker wearing or using specialized clothing or equipment.<br />
The ability <strong>of</strong> a substance to pass through a barrier.<br />
The amount <strong>of</strong> time after the administration <strong>of</strong> hazardous drugs when<br />
patient bodily fluids should be treated as hazardous and handled with safe<br />
handling precautions. The exact time period is determined by the<br />
treatment protocol for the drugs being administered, but most <strong>of</strong>ten it is<br />
48 hours.<br />
Running <strong>of</strong> fluid through tubing to remove air.<br />
Placing a worker in a role that is different than what he or she normally<br />
performs in order to reduce exposure to reproductive toxins.<br />
The process <strong>of</strong> examining the workplace in order to understand where<br />
workers are exposed to a hazard. It is the foundation <strong>of</strong> an exposure<br />
control plan.<br />
A medical sharp with a built-in safety feature or mechanism that eliminates<br />
or minimizes the risk <strong>of</strong> accidental parenteral contact while or after the<br />
sharp is used (for example, using a retracting mechanism or blunt tip).<br />
A control measure used to minimize a hazard by replacing a substance or<br />
process with one that is less hazardous.<br />
Refers to residues <strong>of</strong> hazardous drugs that are deposited on a surface.<br />
A method <strong>of</strong> quantifying hazardous drug surface contamination by<br />
collecting hazardous drug residues on a wipe.<br />
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Appendix 3:<br />
Monitoring the workplace environment<br />
Environmental monitoring, when used, should be carried out:<br />
••<br />
Before implementing controls<br />
••<br />
After any changes (for example, new equipment, new drugs, or<br />
same drugs in a different format) that could affect hazardous<br />
drug contamination<br />
••<br />
After a major exposure event, such as a large spill<br />
••<br />
Periodically in areas <strong>of</strong> concern<br />
Environmental monitoring should also include the following:<br />
••<br />
Compare with records <strong>of</strong> past environmental measurements<br />
(suggested time period is at least five years, but longer may be<br />
useful for research purposes).<br />
••<br />
Involve workers by asking for suggestions on where sampling<br />
should take place and informing them <strong>of</strong> the results <strong>of</strong> any<br />
monitoring activities.<br />
Best Practices for the <strong>Safe</strong> <strong>Handling</strong> <strong>of</strong> <strong>Hazardous</strong> <strong>Drugs</strong> 63
Site <strong>of</strong> handling<br />
Receiving/unpacking areas<br />
Storage areas<br />
Preparation areas<br />
Treatment areas<br />
Other areas<br />
Suggested sampling areas<br />
••<br />
Unpacking table<br />
••<br />
Floors<br />
••<br />
Exterior <strong>of</strong> drug containers<br />
••<br />
Work table<br />
••<br />
Storage shelves<br />
••<br />
Cart<br />
••<br />
Cabinet work surface<br />
••<br />
Floor near cabinet<br />
••<br />
Technician’s chair<br />
••<br />
Product verification counter<br />
••<br />
Exterior <strong>of</strong> drug bags<br />
••<br />
Door handle<br />
••<br />
Counter used for priming/preparing equipment<br />
••<br />
Arms <strong>of</strong> chairs<br />
••<br />
Floor near administration area<br />
••<br />
<strong>Hazardous</strong> drug waste containers<br />
••<br />
Patient waiting room<br />
••<br />
Equipment storage areas<br />
Recommended sampling sites for an environmental monitoring program for hazardous drugs,<br />
adapted from ASSTSAS Prevention Guide – <strong>Safe</strong> <strong>Handling</strong> <strong>of</strong> <strong>Hazardous</strong> <strong>Drugs</strong>. Refer to this<br />
guide for more information on implementing an environmental monitoring program.<br />
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Appendix 4:<br />
Personal protective equipment (PPE)<br />
In the Regulation<br />
PPE that is consistent<br />
with the ECP must be<br />
used where cytotoxic<br />
drugs are present.<br />
This may include:<br />
••<br />
Gloves designed<br />
for use with<br />
cytotoxic drugs<br />
••<br />
Gowns that are<br />
moisture resistant<br />
with long sleeves<br />
and tight-fitted<br />
cuffs<br />
••<br />
Respirators<br />
••<br />
Face and eye<br />
protection<br />
See section<br />
6.55(2)(a) to (d)<br />
Also, see sections<br />
8.40 and 8.41 <strong>of</strong> the<br />
Regulation for the<br />
requirements around<br />
the use <strong>of</strong> respirators.<br />
The specific PPE that is required for each task in the workplace is<br />
determined by a risk assessment. Workers should refer to the safe<br />
work procedures at their workplace for determining what types <strong>of</strong><br />
PPE they are required to wear when handling hazardous drugs.<br />
It is the employer’s responsibility to provide appropriate PPE and<br />
training on its correct use and disposal. Workers are responsible for<br />
wearing supplied PPE when it is needed.<br />
If the PPE is disposable, such as chemotherapy gloves and<br />
chemotherapy gowns, then once it’s been used for hazardous drugs<br />
it must be discarded as hazardous drug waste.<br />
Chemotherapy-tested gloves<br />
Chemotherapy-tested gloves must be worn whenever hazardous<br />
drugs or potentially contaminated objects are handled.<br />
Chemotherapy gloves should meet the requirements <strong>of</strong> ASTM<br />
Standard 6978-05 Standard Practice for Assessment <strong>of</strong> Resistance<br />
<strong>of</strong> Medical Gloves to Permeation by Chemotherapy Gloves.<br />
Chemotherapy-tested gloves should:<br />
••<br />
Not be powdered, as the powder can be contaminated and then<br />
fall <strong>of</strong>f the gloves during removal and contribute to<br />
contamination<br />
••<br />
Be compatible with cleaning and decontaminating agents used in<br />
the workplace<br />
••<br />
Be latex free (acceptable alternatives include neoprene, nitrile,<br />
and polyurethane)<br />
••<br />
Be able to maintain their resistance to permeation by hazardous<br />
drugs when disinfected with alcohol<br />
When following best practices for the use <strong>of</strong> gloves during handling<br />
<strong>of</strong> hazardous drugs, workers should:<br />
••<br />
Wear double gloves when the risk for dermal contamination with<br />
hazardous drugs is high (this is determined as part <strong>of</strong> your<br />
workplace risk assessment)<br />
Best Practices for the <strong>Safe</strong> <strong>Handling</strong> <strong>of</strong> <strong>Hazardous</strong> <strong>Drugs</strong> 65
••<br />
Follow steps to avoid contamination when putting on gloves and<br />
during removal, including washing hands before and after<br />
wearing gloves<br />
••<br />
Change gloves after 30 minutes <strong>of</strong> continuous compounding or if<br />
they have been contaminated or compromised<br />
••<br />
Remove outer gloves before taking them out <strong>of</strong> a biological<br />
safety cabinet<br />
Chemotherapy-tested gowns<br />
Chemotherapy-tested gowns used for handling hazardous drugs<br />
must be worn when there is risk <strong>of</strong> bodily contact with hazardous<br />
drugs or contaminated patient body fluids and waste during the<br />
precautionary period.<br />
Gowns should:<br />
••<br />
Be identified by the manufacturer as gowns for handling<br />
hazardous drugs<br />
••<br />
Be moisture resistant with long sleeves and tight-fitting cuffs<br />
••<br />
Have a closed front that covers the worker from shoulders to<br />
knees and fastens in the back<br />
••<br />
Be disposable<br />
When following best practice for the use <strong>of</strong> chemotherapy gowns<br />
with hazardous drugs, workers should:<br />
••<br />
Change the gown every 3.5 hours or immediately when<br />
contaminated or compromised<br />
••<br />
Wash hands immediately after removing a gown<br />
Chemotherapy gowns should meet the requirements <strong>of</strong> ASTM<br />
Standard F739-99a Standard Test Method for Resistance <strong>of</strong><br />
Protective Clothing Materials to Permeation by Liquids or Gases<br />
under Conditions <strong>of</strong> Continuous Contact or a comparable standard.<br />
Respirators<br />
An approved and fit-tested respirator must be worn when there is a<br />
risk <strong>of</strong> exposure to airborne particulates, aerosols, or vapours from<br />
hazardous drugs.<br />
The respirator selected must provide protection from particulates as<br />
well as gases or vapours that can be generated from solid or liquid<br />
forms <strong>of</strong> hazardous drugs, depending on the activity. This could<br />
include a half-or full-face air-purifying respirator that has a<br />
particulate filter (such as P100) and a chemical cartridge that<br />
removes vapour contaminants from air as it is inhaled.<br />
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The choice <strong>of</strong> respirator must be made as part <strong>of</strong> the risk assessment<br />
based on the potential exposure to airborne particulates, aerosols, or<br />
vapours from hazardous drugs for each task in the workplace. Fit<br />
tests must also be carried out before a respirator is issued to a<br />
worker. The worker must perform a seal check before each use.<br />
Refer to the Work<strong>Safe</strong>BC publication Breathe <strong>Safe</strong>r: How to<br />
Use Respirators <strong>Safe</strong>ly and Start a Respirator Program for more<br />
information on how to select an appropriate respirator.<br />
Face and eye protection<br />
Face protection, such as full or partial face shields and goggles,<br />
should be worn when there is a risk <strong>of</strong> splashing, which may occur<br />
when handling liquid forms <strong>of</strong> hazardous drugs or contaminated<br />
body fluids and waste.<br />
When following best practice for wearing face protection for<br />
hazardous drugs, workers should:<br />
••<br />
Wear full face shields<br />
••<br />
Use disposable face protection whenever practicable<br />
••<br />
Clean non-disposable face protection immediately after use<br />
Footwear and shoe covers<br />
Workers must ensure their footwear is in a condition to provide<br />
protection against exposure to hazardous drugs, such as by wearing<br />
closed shoes that are made <strong>of</strong> a material that prevents liquids from<br />
soaking through. Refer to section 8.22 <strong>of</strong> the Regulation for more<br />
information on the requirements for footwear.<br />
Shoe covers are part <strong>of</strong> sterile preparation procedures but also help<br />
reduce exposure by preventing contamination being spread to other<br />
areas <strong>of</strong> the workplace on workers’ shoes.<br />
Best practices for footwear and shoe covers include, but are not<br />
limited to:<br />
••<br />
Having a dedicated set <strong>of</strong> footwear that is only used in the<br />
preparation area<br />
••<br />
Having all workers wear shoe covers when entering a sterile<br />
preparation room<br />
••<br />
Removing shoe covers with gloved hands and disposing as<br />
hazardous waste upon exiting the preparation room<br />
••<br />
Wearing shoe covers when cleaning up spills or broken<br />
containers on the floor<br />
Best Practices for the <strong>Safe</strong> <strong>Handling</strong> <strong>of</strong> <strong>Hazardous</strong> <strong>Drugs</strong> 67
Appendix 5:<br />
Biological safety cabinets (BSCs)<br />
In the Regulation<br />
Where preparation<br />
activities involving<br />
cytotoxic drugs take<br />
place at the facility, an<br />
approved BSC must<br />
be provided and used.<br />
See section 6.53 <strong>of</strong><br />
the Regulation.<br />
Where a BSC is used,<br />
it must be equipped<br />
with a continuous<br />
airflow monitoring<br />
device where<br />
cytotoxic drugs are<br />
present. See section<br />
6.53(1)(c) <strong>of</strong> the<br />
Regulation.<br />
In the Regulation<br />
Type A1 and A2<br />
cabinets must not<br />
be used for the<br />
preparation <strong>of</strong><br />
cytotoxic drugs. A<br />
minimum Class II Type<br />
B must be used when<br />
preparing cytotoxic<br />
drugs. See section<br />
6.53 <strong>of</strong> the Regulation.<br />
A biological safety cabinet (BSC) should be used for all preparation<br />
activities with hazardous drugs. The information in this appendix<br />
outlines which BSCs are appropriate for use with hazardous drugs.<br />
For more information on BSCs, refer to the Canadian Biosafety<br />
Standards and Guidelines, First Edition.<br />
Class I BSCs<br />
A Class I BSC provides environmental and personnel protection,<br />
but does not provide sterile conditions for the product. The<br />
Regulation states that a Class I BSC is not acceptable for use with<br />
cytotoxic drugs, however it may be permitted if it is designed to be<br />
total exhaust. Depending on whether non-sterile activities are<br />
carried out in the workplace, the use <strong>of</strong> Class I BSCs with<br />
hazardous drugs may need to be evaluated with a Work<strong>Safe</strong>BC<br />
occupational hygiene <strong>of</strong>ficer.<br />
Class II BSCs<br />
Class II Type A BSCs recirculate HEPA-filtered air back into the<br />
preparation room and, because <strong>of</strong> this, do not meet the ventilation<br />
requirements under the Regulation. Since HEPA filters only protect<br />
against particulate contamination and not gases or vapours, this<br />
recirculated air must be considered a potential risk for workers in<br />
the preparation room to be exposed to hazardous drugs. For this<br />
reason, Class II Type A1 and Type A2 BSCs should not be used for<br />
the preparation <strong>of</strong> hazardous drugs.<br />
Class II Type B BSCs do not recirculate HEPA-filtered air into the<br />
preparation room and should be used for ventilation and<br />
containment control for preparations <strong>of</strong> hazardous drugs. However,<br />
it is best practice to use a Class II Type B2 BSC, since they<br />
externally exhaust all air that passes through the cabinet.<br />
Class III BSCs and isolators<br />
Class III BSCs and isolators could potentially provide additional<br />
protection against exposure because they are completely enclosed<br />
and air tight. Unlike other classes <strong>of</strong> BSCs, they have a glass barrier<br />
between the worker and the preparation. When being used for<br />
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containment, they are kept at negative air pressure to the<br />
surrounding room. Preparations enter and exit the BSC via passthrough<br />
hatches with interlocking doors, and workers reach<br />
preparations inside the cabinet by placing their hands inside builtin<br />
glove assembly fixtures.<br />
Class III BSCs and isolators are not typically used for hazardous drug<br />
preparation. Any Class III BSC or isolator used for hazardous drug<br />
preparations must meet the operational requirements for BSCs as<br />
described in the Regulation. Refer to section 30.12 <strong>of</strong> the Regulation.<br />
Class<br />
<strong>of</strong> BSC<br />
Recirculated<br />
air<br />
Permitted for Cytotoxic<br />
<strong>Drugs</strong> under the Regulation<br />
Recommended Best Practice<br />
for <strong>Hazardous</strong> <strong>Drugs</strong><br />
Class I<br />
Can be total<br />
exhaust or<br />
partial exhaust<br />
No<br />
No<br />
Class II<br />
Type A<br />
70% into BSC,<br />
30% into<br />
preparation<br />
room<br />
No<br />
No<br />
Class II<br />
Type B1<br />
30% into<br />
the BSC<br />
Yes<br />
No<br />
Class<br />
II Type<br />
B2<br />
0% Yes Yes<br />
Class III 0% Yes No<br />
A comparison <strong>of</strong> the BSC classes and their uses according to the Regulation and recommended by<br />
best practice.<br />
Best Practices for the <strong>Safe</strong> <strong>Handling</strong> <strong>of</strong> <strong>Hazardous</strong> <strong>Drugs</strong> 69
Appendix 6:<br />
Selection <strong>of</strong> medical equipment<br />
Not all equipment is suitable for use with hazardous drugs.<br />
Where applicable, equipment that is selected for use with<br />
hazardous drugs should:<br />
••<br />
Be approved for use with hazardous drugs by the manufacturer<br />
••<br />
Eliminate or minimize the release <strong>of</strong> hazardous drugs in the form<br />
<strong>of</strong> liquids, solids, or vapours as much as reasonably possible<br />
••<br />
Clearly indicate any functions where the equipment is not a<br />
closed system, if it is marketed as a closed-system transfer<br />
device<br />
••<br />
Be supported by evidence that demonstrates the effectiveness <strong>of</strong><br />
the equipment at reducing environmental contamination in<br />
occupational settings<br />
Employers should periodically review the equipment and supplies<br />
used for hazardous drugs for their effectiveness at reducing<br />
exposure.<br />
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Appendix 7: Cleaning agents<br />
Effective cleaning and decontamination is a key part <strong>of</strong> reducing<br />
hazardous drug surface contamination. <strong>Hazardous</strong> drug<br />
contamination has been detected on surfaces even after cleaning<br />
using conventional methods and cleaning products. <strong>Hazardous</strong><br />
drug contamination may accumulate in porous materials.<br />
No single cleaning agent can be used in all situations. The<br />
effectiveness <strong>of</strong> a cleaning or decontaminating agent depends on<br />
the chemical and physical properties <strong>of</strong> the drug, as well as the<br />
surface that is being cleaned.<br />
Workplaces should have multiple cleaning and decontaminating<br />
supplies that are effective on different drugs, or at least different<br />
types <strong>of</strong> drugs based on their chemical and physical properties.<br />
When selecting cleaning and decontamination supplies,<br />
workplaces should consider:<br />
••<br />
Current research on the effectiveness <strong>of</strong> different procedures<br />
and agents on the types <strong>of</strong> hazardous drugs being used in the<br />
workplace<br />
••<br />
Surfaces (e.g., stainless steel BSC) that may have specific<br />
cleaning requirements outlined by the manufacturer<br />
••<br />
The characteristics <strong>of</strong> the surfaces that will be cleaned and<br />
decontaminated, such as porosity and texture<br />
••<br />
The ease <strong>of</strong> use, such as having pre-packaged wipes soaked in<br />
solution<br />
••<br />
The potential for hazardous by-products from cleaning and<br />
decontamination products, or products that are hazardous<br />
themselves<br />
Best Practices for the <strong>Safe</strong> <strong>Handling</strong> <strong>of</strong> <strong>Hazardous</strong> <strong>Drugs</strong> 71
The table below compares some <strong>of</strong> the cleaning and decontaminating agents commonly used<br />
on surfaces that may have hazardous drug contamination.<br />
Deactivating<br />
agent<br />
Decontaminating<br />
agent<br />
Disinfecting<br />
agent<br />
Cleaning<br />
agent<br />
Mode <strong>of</strong><br />
action<br />
Breaks down<br />
hazardous drugs<br />
Physically removes<br />
hazardous drugs<br />
Surface<br />
disinfection<br />
Removes<br />
organic and<br />
inorganic<br />
material<br />
Examples<br />
Hypochlorite<br />
(household bleach)<br />
Laboratory-grade<br />
detergents<br />
Ethyl alcohol,<br />
70% isopropyl<br />
alcohol<br />
Chlorhexidine<br />
Benefits<br />
••<br />
Highly effective at<br />
deactivating<br />
several commonly<br />
used hazardous<br />
drugs<br />
••<br />
Relatively safer<br />
than bleach<br />
••<br />
Convenience<br />
••<br />
Use <strong>of</strong> different<br />
solvents can<br />
improve<br />
efficiency against<br />
different drugs<br />
••<br />
Commonly<br />
used in<br />
routine<br />
disinfection<br />
procedures<br />
••<br />
Commonly<br />
used in<br />
routine<br />
cleaning<br />
procedures<br />
Challenges<br />
••<br />
Can produce<br />
hazardous byproducts<br />
••<br />
Known to corrode<br />
stainless steel (this<br />
can be minimized<br />
by following with a<br />
neutralizing agent)<br />
••<br />
Can cause skin,<br />
eye, and respiratory<br />
irritation<br />
••<br />
May be<br />
less effective<br />
when<br />
contamination<br />
is unknown<br />
••<br />
Higher<br />
concentrations<br />
may leave<br />
residues that can<br />
trap hazardous<br />
drugs<br />
••<br />
Do not directly act on<br />
hazardous drugs<br />
••<br />
Can leave residues that trap<br />
microbes or hazardous drugs<br />
and spread them around<br />
••<br />
Should not be used as the sole<br />
agent for removing hazardous<br />
drug contamination<br />
72<br />
Best Practices for the <strong>Safe</strong> <strong>Handling</strong> <strong>of</strong> <strong>Hazardous</strong> <strong>Drugs</strong>
Appendix 8: Spill kit checklist<br />
In the Regulation<br />
Spill kits must be<br />
present where<br />
cytotoxic drugs are<br />
used in the workplace.<br />
See section 6.58(2) <strong>of</strong><br />
the Regulation.<br />
Spill kits should be available wherever hazardous drugs are<br />
handled. Best practices for the contents <strong>of</strong> a spill kit include:<br />
Laminated, written instructions<br />
<br />
Warning signs and plastic “caution” tape to alert other staff to<br />
the hazard and to isolate the spill area<br />
Personal protective equipment (PPE):<br />
Chemotherapy-tested gown<br />
Two pairs <strong>of</strong> chemotherapy-tested gloves<br />
Disposable eye goggles or face shield<br />
Shoe covers<br />
N95 or better respirator mask<br />
Disposable scoop and scraper<br />
<br />
<br />
An absorbent spill pad for small volumes <strong>of</strong> liquid<br />
A spill pillow capable <strong>of</strong> absorbing very large volumes <strong>of</strong> liquid<br />
(if not practical to fit inside the spill kit, this may be located<br />
separately and retrieved when required)<br />
Two large plastic waste disposal bags<br />
Concentrated alkaline detergent solution<br />
<br />
<br />
<br />
Bottled water, <strong>of</strong> the correct volume for diluting the detergent<br />
Clearly labelled hazardous waste container<br />
Information on reporting the spill and potential worker exposure<br />
Best Practices for the <strong>Safe</strong> <strong>Handling</strong> <strong>of</strong> <strong>Hazardous</strong> <strong>Drugs</strong> 73
Work<strong>Safe</strong>BC <strong>of</strong>fices<br />
Visit our website at worksafebc.com.<br />
Abbotsford<br />
2774 Trethewey Street V2T 3R1<br />
Phone 604.276.3100<br />
1.800.292.2219<br />
Fax 604.556.2077<br />
Burnaby<br />
450 – 6450 Roberts Street V5G 4E1<br />
Phone 604.276.3100<br />
1.888.621.7233<br />
Fax 604.232.5950<br />
Coquitlam<br />
104 – 3020 Lincoln Avenue V3B 6B4<br />
Phone 604.276.3100<br />
1.888.967.5377<br />
Fax 604.232.1946<br />
Courtenay<br />
801 30th Street V9N 8G6<br />
Phone 250.334.8765<br />
1.800.663.7921<br />
Fax 250.334.8757<br />
Kamloops<br />
321 Battle Street V2C 6P1<br />
Phone 250.371.6003<br />
1.800.663.3935<br />
Fax 250.371.6031<br />
Kelowna<br />
110 – 2045 Enterprise Way V1Y 9T5<br />
Phone 250.717.4313<br />
1.888.922.4466<br />
Fax 250.717.4380<br />
Nanaimo<br />
4980 Wills Road V9T 6C6<br />
Phone 250.751.8040<br />
1.800.663.7382<br />
Fax 250.751.8046<br />
Nelson<br />
524 Kootenay Street V1L 6B4<br />
Phone 250.352.2824<br />
1.800.663.4962<br />
Fax 250.352.1816<br />
North Vancouver<br />
400 – 224 Esplanade Ave. W. V7M<br />
1A4<br />
Phone 604.276.3100<br />
1.888.875.6999<br />
Fax 604.232.1558<br />
Prince George<br />
1066 Vancouver Street V2L 5M4<br />
Phone 250.561.3700<br />
1.800.663.6623<br />
Fax 250.561.3710<br />
Surrey<br />
100 – 5500 152 Street V3S 5J9<br />
Phone 604.276.3100<br />
1.888.621.7233<br />
Fax 604.232.7077<br />
Terrace<br />
4450 Lakelse Avenue V8G 1P2<br />
Phone 250.615.6605<br />
1.800.663.3871<br />
Fax 250.615.6633<br />
Victoria<br />
4514 Chatterton Way V8X 5H2<br />
Phone 250.881.3418<br />
1.800.663.7593<br />
Fax 250.881.3482<br />
Head Office / Richmond<br />
Prevention Information Line:<br />
Phone 604.276.3100<br />
1.888.621.7233 (621.SAFE)<br />
Administration:<br />
6951 Westminster Highway<br />
Phone 604.273.2266<br />
Mailing Address:<br />
PO Box 5350 Stn Terminal<br />
Vancouver BC V6B 5L5<br />
After hours<br />
health & safety emergency<br />
604.273.7711<br />
1.866.922.4357 (WCB.HELP)<br />
R13/09
11/15 Printed in Canada<br />
BK153