Safe Handling of Hazardous Drugs

Best Practices for the 

Safe Handling 

of Hazardous Drugs

About WorkSafeBC 

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Best Practices for the 

Safe Handling 

of Hazardous Drugs

WorkSafeBC publications 

Many publications are available on the WorkSafeBC website. The Occupational Health and 

Safety Regulation and associated policies and guidelines, as well as excerpts and summaries of 

the Workers Compensation Act, are also available on worksafebc.com. 

Some publications are also available for purchase in print: 

Phone: 604.232.9704 

Toll-free phone: 1.866.319.9704 

Fax: 604.232.9703 

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Online ordering: worksafebc.com and click on Publications; follow the links for ordering 

ISBN 978-0-7726-6927-8 

©2015 Workers’ Compensation Board of British Columbia. All rights reserved. The Workers’ 

Compensation Board of B.C. encourages the copying, reproduction, and distribution of this 

document to promote health and safety in the workplace, provided that the Workers’ 

Compensation Board of B.C. is acknowledged. However, no part of this publication may be 

copied, reproduced, or distributed for profit or other commercial enterprise, nor may any part 

be incorporated into any other publication, without written permission of the Workers’ 

Compensation Board of B.C.

Acknowledgments 

WorkSafeBC thanks the many organizations who generously donated their time and knowledge to 

reviewing this edition of Best Practices for the Safe Handling of Hazardous Drugs, including: 

•• 

BC Provincial Hazardous Drugs Working Group 

•• 

BC Provincial Hazardous Drug List Working Group 

•• 

College of Pharmacists of BC 

•• 

University of British Columbia 

•• 

BC Nurses’ Union 

•• 

College of Veterinarians of BC 

•• 

Health Sciences Association of BC

Contents 

About this book. ................................ 1 

Part 1: Hazardous drugs in the workplace ............. 3 

1. What are hazardous drugs? ...........................5 

2. Who is at risk of exposure? ...........................6 

3. Why are workers at risk? .............................7 

4. Routes of occupational exposure .......................8 

5. Creating an exposure control plan .....................10 

Part 2: Performing a risk assessment for hazardous drugs. ..11 

6. What is a risk assessment? ..........................13 

7. Identifying hazardous drugs ..........................15 

8. Assessing risk .....................................17 

8.1 Tools for assessing risk ..........................18 

9. Developing and implementing control measures .........20 

10. Written safe work procedures .......................23 

11. Information and communication .....................24 

11.1 Education and training ..........................25 

11.2 Written records ...............................25 

Part 3: Task-specific guidelines for reducing exposure 

to hazardous drugs. ............................. 27 

12. Drug shipping ....................................29 

13. Drug receiving and storage ..........................30 

13.1 Work area design .............................30 

13.2 Equipment ...................................31 

13.3 Guidelines for safe work practice .................31 

13.4 Personal protective equipment (PPE) ..............31 

14. Drug transport ....................................32 

14.1 Equipment ...................................32 



15. Drug preparation ..................................33 


15.2 Equipment ...................................34 


15.4 Cleaning .....................................36 


Best Practices for the Safe Handling of Hazardous Drugs 

v

16. Drug administration ...............................38 


16.2 Drug administration equipment ..................38 


16.4 Cleaning .....................................39 

16.5 Considerations for home care ...................40 


17. Veterinary practice. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 

17.1 Work area design ..............................42 

17.2 Equipment ...................................43 


17.4 Cleaning .....................................43 


18. Patient care ......................................45 


18.2 Equipment ...................................45 

18.3 Guidelines for Safe Work Practice ................46 

18.4 Cleaning .....................................46 


19. Cleaning .........................................47 



20. Waste disposal ...................................48 


20.2 Equipment ...................................49 

20.3 Guidelines for safe work practice ................49 

20.4 Personal protective equipment (PPE) .............50 

21. Spill response ....................................51 


21.2 Personal protective equipment (PPE)..............51 

Appendices ................................... 53 

Appendix 1: References and resources ...................55 

Appendix 2: Glossary .................................60 

Appendix 3: Monitoring the workplace environment ........63 

Appendix 4: Personal protective equipment (PPE) ..........65 

Appendix 5: Biological safety cabinets (BSCs)..............68 

Appendix 6: Selection of medical equipment ..............70 

Appendix 7: Cleaning agents ...........................71 

Appendix 8: Spill kit checklist ..........................73 

vi 

Best Practices for the Safe Handling of Hazardous Drugs

About this book 

This book deals with the health and safety of workers who handle 

hazardous drugs. It is meant to be a starting point and a reference 

guide of best practices to minimize worker exposure to hazardous 

drugs in the workplace. This book has three parts: 

•• 

Part 1 gives an overview of current knowledge on hazardous drugs 

•• 

Part 2 describes how to perform a risk assessment 

•• 

Part 3 gives examples of best practices for each stage of 

handling hazardous drugs 

The book also includes eight appendices: 

•• 

Appendix 1: References and resources 

•• 

Appendix 2: Glossary 

•• 

Appendix 3: Monitoring the workplace environment 

•• 

Appendix 4: Personal protective equipment (PPE) 

•• 

Appendix 5: Biological safety cabinets (BSCs) 

•• 

Appendix 6: Selection of medical equipment 

•• 

Appendix 7: Cleaning agents 

•• 

Appendix 8: Spill kit checklist 

Who this book is intended for 

This book is intended primarily for the health care industry in B.C., 

including those engaged in community or home-based care. 

However, Part 3 also provides guidelines for ancillary services, 

such as transportation and cleaning, and for veterinary practices. 

See Chapter 2: “Who is at risk of exposure?” for a list of occupations 

in which workers are at potential risk of exposure to hazardous drugs. 

Terminology 

Appendix 2 contains a glossary of terms frequently used when 

handling hazardous drugs. When these terms appear in the text of 

this book, they will be indicated with bold type. If you place your 

cursor over the bold text, a pop-up box will appear with the 

definition of the term. 

Best Practices for the Safe Handling of Hazardous Drugs 1

Legal considerations 

While the information in this book is meant to help you meet the 

requirements specified in the Occupational Health and Safety 

Regulation (the Regulation), it does not replace it. You will need to 

refer to the Regulation to determine the exact requirements that 

apply to your particular workplace. 

In Canada, drug products fall under the jurisdiction of the 

Food and Drugs Act and are exempt from WHMIS requirements. 

However, information requirements under section 5.2 of the 

Regulation still apply. Chapter 10 provides more information on 

how to comply with the Regulation. 

Best practices: hazardous and cytotoxic drugs 

This book contains recommended best practices that apply when 

handling all hazardous drugs. We use the term hazardous drugs to 

indicate that occupational exposure should be controlled in the 

workplace for all drugs that meet the specified criteria. Employers 

should perform a risk assessment before adopting any of the 

recommendations in this book. 

While recommended practice is to reduce worker exposure to any 

hazardous drug, exposure to cytotoxic drugs, a subset of hazardous 

drugs, is specifically regulated by Part 6 of the Regulation. 

Cytotoxic drugs are defined in section 6.42 of the Regulation as 

drugs that “... possess a specific destructive action on certain cells 

or that may be genotoxic, oncogenic, mutagenic, teratogenic, or 

hazardous to cells in any way and includes most anti-cancer drugs.” 

Where cytotoxic drugs are present in the workplace the employer 

must ensure that the legal requirements are being met. 

When you see this symbol, it indicates a specific legal 

requirement from the Occupational Health and Safety 

Regulation (the Regulation) when cytotoxic drugs are 

present in the workplace. 

2 


Part 1: Hazardous drugs 

in the workplace 

The following chapters provide an overview of current knowledge on hazardous drugs. 

This will help you understand what hazardous drugs are, why they are hazardous, and 

who is at risk of exposure. Routes of occupational exposure are also covered, as well 

as what kind of information should be included in an exposure control plan.

1. What are hazardous drugs? 

Hazardous drugs are specific drugs with the potential to harm 

workers who are exposed to them. Continual or frequent exposures 

to low levels of hazardous drugs, or a single exposure to a larger 

amount, can put workers at risk of negative health effects. 

Refer to Appendix 1: References and Resources for a list of studies 

that provide evidence on the potential health risks of occupational 

exposure to hazardous drugs. 

This book uses the definition of a hazardous drug that the National 

Institute for Occupational Health and Safety (NIOSH) developed. 

According to NIOSH’s definition, a drug is hazardous if there is 

evidence of one or more of the following characteristics in humans 

or animals: 

•• 

Carcinogenicity: the ability to cause cancer 

•• 

Teratogenicity or other developmental toxicity: the ability to 

affect the development of an embryo or fetus 

•• 

Reproductive toxicity: the ability to affect reproductive function 

in adults 

•• 

Organ toxicity at low doses: the ability to seriously affect organs 

or organ systems 

•• 

Genotoxicity: the ability to damage genetic material within cells 

NIOSH determines whether drugs meet these criteria by reviewing 

existing scientific evidence for each drug and then lists qualified 

drugs in a periodical. Visit the NIOSH Hazardous Drugs web page 

for the most recent list of hazardous drugs. 

For drugs not on the NIOSH list, employers can determine whether 

a drug is considered hazardous by using the following sources of 

information: 

•• 

Evidence-based research that indicates the drug meets the 

criteria for a hazardous drug 

•• 

Drug information sheets provided by the manufacturer, such as 

safety data sheets 

•• 

Product monographs in Health Canada’s Drug Product Database 

•• 

Health warnings from government or professional groups 


2. Who is at risk of exposure? 

A wide range of people can be at risk of exposure to hazardous 

drugs in their workplace, including: 

•• 

Pharmacy workers 

•• 

Laboratory workers 

•• 

Nurses 

•• 

Health care assistants 

•• 

Cleaners, housekeeping and laundry staff 

•• 

Physicians 

•• 

Veterinary and animal attendant workers 

•• 

Community health workers 

•• 

Workers involved in drug shipping/receiving/transport services 

•• 

Workers involved in hazardous waste services 

6 


3. Why are workers at risk? 

In the past most hazardous drugs were antineoplastic, which refers 

to drugs used to treat cancer. However, hazardous drugs are 

increasingly being used to treat diseases other than cancer, such as: 

•• 

Rheumatoid arthritis 

•• 

Skin psoriasis 

•• 

Multiple sclerosis 

•• 

Some viral diseases, such as HIV 

•• 

Hormone-dependent cancers 

Hazardous drugs are increasingly being administered in nontraditional 

settings—including community or home care, and 

physician and veterinary practices. In these workplaces, there may 

not be well-established control measures in place to minimize 

occupational exposure. Part 3 touches on these workplaces and 

provides practical, task-based information on working with 

hazardous drugs in these environments. 

With the growing potential for exposure to hazardous drugs, it is 

essential that all workplaces where hazardous drugs are present 

have effective measures in place to control worker exposure. 


4. Routes of occupational exposure 

Workers can be exposed to hazardous drugs in a number of ways. 

The potential route of exposure depends on the form of the drug 

being handled and the tasks being conducted. The table on page 9 

shows the main routes of worker exposure and gives some examples 

of activities where these exposures may take place. It also gives 

examples of controls that may be used to minimize these routes of 

exposure to workers. 

Surface contamination is one of the main sources of occupational 

exposure to hazardous drugs. Due to their chemical stability, 

residue from hazardous drugs can persist in the workplace 

and be spread far from their point of origin. Trace residue from 

hazardous drugs can deposit on surfaces, such as vials and IV 

bags containing hazardous drugs, work tables, and hazardous 

drug transport carts. Residue can also collect on items that are 

not directly used for handling hazardous drugs, such as pens, 

door handles, and elevator buttons. Since surfaces throughout 

the workplace may be contaminated, there is a potential risk of 

exposure to others present in the workplace, including visiting 

staff or patient family members. Refer to Appendix 1 for scientific 

research on surface contamination. 

8 


Route of exposure Examples of activities Possible controls 

Direct dermal 

contact 

Indirect dermal 

contact 

Contact with eyes 

Inhalation 

Percutaneous 

exposure 

Ingestion 

•• 

Handling oral or topical forms of 

hazardous drugs 

•• 

Contact with a leak or spill of 


•• 

Handling contaminated patient 

excreta 

•• 

Handling or touching contaminated 

materials, such as equipment, 

containers, work surfaces, patient 

laundry 

•• 

Handling liquid forms of hazardous 

drugs 

•• 

Inhaling aerosols or vapours 

released when priming equipment 

•• 

Inhaling particulate material 

released when crushing tablets or 

opening capsules 

•• 

Preparing or administering drugs 

using a needle 

•• 

Eating food that has been 

contaminated with hazardous 

drugs 

•• 

Wearing double 

chemotherapy-tested gloves 

•• 

Using a closed-system transfer 

device 

•• 

Wearing double 

chemotherapy-tested gloves 

•• 

Observing a precautionary 

period for handling patient 

excreta 

•• 

Wearing eye protection or a 

face shield 

•• 

Performing activities inside a 

biological safety cabinet 

•• 

Wearing an appropriate 

respirator 

•• 

Using a needleless system or 

safety engineered medical 

sharp 

•• 

Ensuring all food is stored away 

from areas where hazardous 

drugs are handled 

•• 

Proper hand washing 

The selection of appropriate controls is discussed in Chapter 9. 

Refer to Appendix 1 for additional resources that provide scientific evidence for these routes of 

exposure. 


5. Creating an exposure control plan 

In the Regulation 

Workplaces where 

cytotoxic drugs are 

present must have an 

exposure control plan 

in place. See sections 

5.54(1) and 6.43 of 

the Regulation. 

The employer must 

review the exposure 

control plan at least 

annually and update 

if required. See 

section 5.54(3) of the 

Regulation. 


Where cytotoxic 

drugs are present in 

the workplace, the 

exposure control 

plan for the must be 

periodically reviewed. 

See section 5.54 of 


An exposure control plan (ECP) describes how workers will be 

protected from hazardous drugs in the workplace. An ECP includes 

information on the nature of the hazard and the risk associated with 

exposure, as well as controls that the employer will use to protect 

workers. 

The ECP includes the following components, which are detailed in 

section 5.54(2) of the Regulation: 

•• 

Statement of purpose and responsibilities 

•• 

Risk identification and assessment 

•• 

Risk controls 

•• 

Written safe work procedures 

•• 

Education and training 

•• 

Written records 

•• 

Hygiene facilities and decontamination procedures (when 

required) 

•• 

Health monitoring (when required) 

The ECP should be reviewed at least annually and updated as 

necessary by the employer, in consultation with the joint 

occupational health and safety committee or the worker health and 

safety representative. 

10 


Part 2: Performing a risk 

assessment for hazardous 

drugs 

Chapters 6 to 9 detail the three steps involved in a risk assessment: identifying 

hazardous drugs, assessing risk of exposure, and implementing controls to eliminate or 

minimize exposure. 

Chapter 10 explains written safe work procedures and Chapter 11 outlines the 

different ways that hazardous drugs are labelled and communicated, as well as 

individual education and training.

6. What is a risk assessment? 


Risk assessments 

must be performed 

where cytotoxic 

drugs are present. 

See section 5.54(2) of 


A risk assessment provides a foundation for eliminating or 

minimizing worker exposure to hazardous drugs in your workplace. 

It involves examining the level to which workers are being exposed 

to hazardous drugs and what can be done to reduce that exposure 

as much as practicable. 

A risk assessment involves performing the following three steps, 

which are discussed in more detail in the subsequent chapters: 

•• 

Identify hazardous drugs that are present in the workplace. 

•• 

Assess the risks of exposure to hazardous drugs. 

•• 

Develop and implement controls to eliminate or reduce exposure. 

A risk assessment should be performed by an individual or team 

who, through a combination of education, training, and experience, 

are knowledgeable about the work, the hazards involved, and the 

means to control the hazards. 

Throughout this process, it‘s essential that front-line workers and 

representatives from the joint occupational health and safety 

committee of your workplace are consulted. Workers and their 

representatives provide knowledge on how work is being done and 

insight into potential solutions. The most effective solutions to 

controlling exposure will take the needs and knowledge of the 

worker into account. 


The following diagram shows the steps to performing a risk assessment. 

Employee 

Consultation 

Health and safety 

representative 

Hazard identification 

Risk assessment 

Risk control 

Elimination (of the hazard) 

Substitution 

Engineering 

Evaluation of controls 

Administration 

Personal 

protective 

equipment 

Trial and implement controls 

Permission provided by WorkSafe Victoria to reproduce this diagram. 

14 


7. Identifying hazardous drugs 


A list of cytotoxic 

drugs must be 

created if they 

are present in the 

workplace. See 

section 6.47 of the 

Regulation. 

Identifying hazards is the first step toward controlling exposure to 

hazardous drugs in your workplace. This involves creating an 

inventory of all drugs in the workplace and then determining 

whether hazardous drugs are present among them. 

Create a list of hazardous drugs in your workplace 

Once you’ve listed all the drugs that are present in your workplace, 

compare them with known hazardous drugs. Visit the following 

websites to view the most recent hazardous drug lists: 

•• 

BC Cancer Agency 

•• 

NIOSH Hazardous Drugs 

If you don’t find a drug on the list, it should be reviewed to determine 

if it is hazardous, using the criteria discussed in Chapter 1. 

Document hazardous drug details 

Once the presence of hazardous drugs in the workplace has been 

established, information needs to be gathered and reviewed for each 

hazardous drug. The following table shows the potential routes of 

exposure, the form of the substance, and the potential health effects. 


Obtain and review information about hazardous drugs used 

Determine the routes 

of exposure. 

Determine the form of 

the substance. 

Ascertain the potential 

harmful effects. 

These may include: 

•• 

Inhalation of aerosols, particulates, and droplets 

•• 

Skin or eye contact through splash of liquid 

•• 

Ingestion through poor personal hygiene or splash of liquid 

•• 

Injection resulting from injuries from sharps 

This may include: 

•• 

Liquid 

•• 

Powder 

•• 

Tablet 

•• 

Creams, ointments, and lotions for topical application 

These may include: 

•• 

Carcinogenic, mutagenic, or teratogenic potential 

•• 

Alterations to normal blood cell count 

•• 

Fetal loss in pregnant women and malfunctions in the offspring of 

pregnant women 

•• 

Abnormal pain, hair loss, nasal sores, vomiting 

•• 

Liver damage 

•• 

Contact dermatitis, local toxic or allergic reaction, irritation to the skin 

Approval to reproduce adapted version from WorkSafe Victoria. 

16 


8. Assessing risk 


A risk assessment 


where cytotoxic drugs 

are present. See 

sections 5.54(2)(b) and 

6.43 of the Regulation. 

Once the presence of hazardous drugs has been identified, the next 

step is to determine the level of risk. This involves determining how 

the drugs are used in the workplace and identifying which tasks 

place workers at risk of exposure. 

Evaluation involves analyzing the work environment, tasks and 

activities performed, and any previous incidents where workers 

may have been exposed to hazardous drugs. This information can 

be gathered by performing a walk-through survey of the workplace, 

consulting with workers who are performing the tasks being 

evaluated, and reviewing employer health and safety records. See 

the following table for more details. 

Evaluate the nature of the work involving hazardous drugs 

Divide up the 

workplace and 

determine where 

hazardous drugs are 

used. 

Examine the work 

practices and 

conditions. 

Involve employees 

who are working with 

the hazardous drugs. 

Review information 

relating to incidents 

or symptons of 

exposure. 

For example: 

•• 

Drug preparation in the pharmacy 

•• 

Drug administration in the ward or daycare centre 

•• 

Handling, transport, and disposal of hazardous waste on the 

premises 

•• 

Patient care after adminstration 

What to look for: 

•• 

How substances are used in various jobs 

•• 

The quantities used 

•• 

Level of potential exposure 

•• 

Frequency and duration of use 

•• 

The number of employees that may be exposed 

•• 

Risk control measures already in place and their effectiveness 

What to do: 

•• 

Review incident records. 

•• 

Identify any problems associated with storage and transport of 

hazardous drugs. 

•• 

Determine whether employees have suffered any adverse effects. 

•• 

Ascertain whether there have been any spills. 

•• 

Determine if incidents have been reported and followed up. 

Approval to reproduce adapted version from WorkSafe Victoria. 


8.1 Tools for assessing risk 

You can use one or all of the following assessment tools to help 

you determine the level of risk posed by hazardous drugs in your 

workplace: 

•• 

Categorizing hazardous drugs 

•• 

Environmental monitoring 

•• 

Health monitoring 

Categorizing hazardous drugs 

For workplaces that use a wide variety or a large number of 

hazardous drugs, it may be helpful to categorize them in terms of 

the degree of risk of exposure. This may make it easier for the 

employer to communicate to workers situations where they are at 

high risk of exposure. This would be based on information about 

the drug itself, such as the form of the drug, potential routes of 

exposure, and potential health effects, as well as information on the 

how the drug is used in the workplace, as determined in the risk 

assessment. 

Check to see if your workplace uses a hazardous drug classification 

system for assessing hazardous drugs. 

Categorizing hazardous drugs may help when developing safe 

handling practices that are based on the risk of worker exposure 

and are suitable for each stage of handling hazardous drugs. 

Categorizing hazardous drugs is a tool that may be used for 

assessing risk, or you may find that other means are more useful or 

practicable in your workplace. 

Environmental monitoring 

Another tool that may be used as part of the risk assessment process 

is environmental monitoring. For example, surface wipe sampling 

measures surface contamination of selected sites of the work 

environment by taking wipe samples and analyzing them in a 

laboratory for the presence of hazardous drug contamination. 

Sampling surfaces throughout the workplace can help provide a 

picture of how hazardous drug contamination is spread throughout 

different stages of handling. Refer to Appendix 3 for more 

information on environmental monitoring. 

Hazardous drug contamination throughout the workplace should 

be kept as low as possible. The goal of environmental monitoring, if 

it is used, is to establish baseline measurements of hazardous drug 

contamination in the workplace with which future measurements 

can be compared. Future measurements can be monitored for 

18 


eductions in contamination over a period of time or as the result of 

interventions that have been implemented. These comparisons can 

help determine areas where interventions were successful and set 

targets for future improvements. 

Health monitoring 

Health monitoring is intended to prevent the development of 

occupational disease in workers by detecting biomarkers in blood 

or urine samples that indicate early signs of disease. For hazardous 

drugs, this can be difficult in practice because the health outcomes 

due to exposure are not yet fully understood. 

There are also methods to detect hazardous drugs (or their 

metabolites) in blood or urine. These tests should always be 

interpreted with caution, as detecting signs of exposure does not 

necessarily mean that disease will develop. 

Health monitoring is typically used in a research setting. If health 

monitoring is used in the workplace, it can help inform a risk 

assessment by tracking whether worker exposure to hazardous 

drugs changes over a period of time. However, health monitoring is 

not a required component of an exposure control plan since these 

methods are not all easily available or validated. 


9. Developing and implementing 

control measures 


Control measures 

must be identified 


drugs are present in 

the workplace and 

implemented in the 

order shown. See 


Regulation. 

Once all hazardous drugs have been identified and the risks 

assessed, appropriate controls should be chosen that reduce the 

risk of exposure to workers. Controls aim to eliminate or reduce 

exposure to workers. As shown in the diagram below, one or more 

of these controls should be implemented in the following order: 

(1) Elimination or substitution 

(2) Engineering controls 

(3) Administrative controls 

(4) Personal protective equipment (PPE) 

Most 

effective 

Elimination/substitution 

Physically remove or 

replace the hazard 

Engineering controls 

Isolate workers 

from the hazard 

Administrative & 

work practices 

controls 

Change the way 

workers work 

PPE 

Protect workers with 

personal protective equipment 

Least 

effective 

20 


The following table provides a description and examples for each type of control. 

Type of Control Description Examples 

Elimination 

Substitution 

Engineering 

controls 

Administrative 

controls 

PPE 

Elimination of hazardous drugs 

from the workplace is not typically 

possible because these drugs may 

be the only treatment available. 

Substitution includes using 

a drug that is less hazardous, 

either because of the form it is 

administered in or its toxicological 

properties (provided it is just as 

effective at treating the patient). 

Engineering controls protect 

workers by physically changing 

the work environment to minimize 


Administrative controls aim 

to reduce exposure in the work 

environment by changing how 

work is carried out. 

PPE controls exposure at the point 

of the individual worker. It is last in 

the hierarchy of controls because 

it requires the most activity and 

is the least effective means of 

limiting worker exposure. PPE will 

often have to be worn despite the 

presence of other control methods. 

•• 

Removing unneeded hazardous 

drugs from the workplace 

•• 

Having drugs delivered in a form 

that is ready to administer 

•• 

Eliminating the number of times 

hazardous drugs are handled 

•• 

Using a form of hazardous drugs 

that has a lower risk of exposure 

to workers, such as tablets instead 

of IV infusions (if clinically 

appropriate) 

•• 

Using an appropriate biological 

safety cabinet 

•• 

Having negative pressure 

preparation rooms or anterooms 

•• 

Using closed-system transfer 

devices 

•• 

Regular hand washing 

•• 

Implementing an effective 

cleaning routine 

•• 

Protective reassignment 

•• 

Developing and implementing 

safe work procedures 

•• 

Chemotherapy-tested gloves 

•• 

Chemotherapy-tested gowns 

•• 

Respirators 

•• 

Eye and face protection 

•• 

Footwear and shoe covers 


Workers exposed to reproductive toxins: protective 

reassignment 

Some hazardous drugs may also be reproductive toxins. According 

to section 6.49 of the Regulation, where reproductive toxins are 

present in cytotoxic drugs, the employer must develop procedures 

to reduce the risk of exposure to workers who are pregnant or who 

are trying to conceive a child. 

An administrative control method of achieving this is protective 

reassignment. This is where the worker is assigned to alternative 

tasks that reduce the risk of their exposure to hazardous drugs. 

Some examples of protective reassignment include, but are not 

limited to: 

•• 

Moving the worker to a different area that does not involve 

exposure to hazardous drugs 

•• 

Assigning the worker to tasks where they won’t be exposed to 


•• 

Reducing shift hours working in areas where hazardous drugs 

are handled 

22 


10. Written safe work procedures 


Safe work procedures 

must be in place 

and posted where 

cytotoxic drugs 

are present in the 

workplace. See 


Regulation. 

Written safe work procedures that are specific to the tasks 

performed at the workplace are an important part of ensuring that 

information on minimizing exposure is communicated to workers. 

Safe work procedures must be available to workers. 

Examples of safe work procedures to be developed and 

communicated to workers include: 

•• 

Appropriate safe work procedures for all tasks and activities 

involving hazardous drugs, including but not limited to, receiving, 

storage, preparation, administration, and waste handling 

•• 

PPE requirements for each stage of handling and related worker 

and employer responsibilities 

•• 

Requirements for proper hygiene, including proper hand washing 

and the prohibition of eating, drinking, smoking, applying 

cosmetics, and storing food where hazardous drugs are present 

•• 

Procedures for documenting acute exposures and reporting 

suspected exposures 

•• 

Procedures for emergency spills, including medical treatment 

and personnel decontamination for acute exposures and proper 

cleanup 

•• 

Procedures for hazardous drug waste disposal 


11. Information and communication 


Where cytotoxic 

drugs are present 

in the workplace, 

information must 

be communicated 

to workers in the 

form of labels, signs, 

lists, education and 

training, and written 

records. See sections 

6.45, 6.46, 6.47, 

6.50, and 6.52 of the 

Regulation. 

[Picture: Sample Hazardous Drugs Warning Labe 

In Canada, drug products fall under the jurisdiction of the Food 

and Drugs Act and are exempt from WHMIS requirements. 

However, information requirements under section 5.2 of the 

Regulation still apply. These requirements include communicating 

information about hazardous drugs to workers via: 

•• 

Labels, signs, and lists 

•• 

Education and training 

•• 

Written records 

Labels, signs, and lists 

CAUTION CHEMOTHERAPY 

Authorized Personnel Only 

If workers are exposed to hazardous drugs, this information must 

be communicated to workers, including those who may not be 

proficient in English. This may be done by: 

•• 

Ensuring all hazardous drugs are labelled to identify them as 

hazardous 

•• 

Posting warning signs to workers in areas where hazardous drugs 

are present 

•• 

Maintaining a list of all hazardous drugs present in the workplace 

: Sample Hazardous Drugs Warning Labels and Signs] 

CAUTION CHEMOTHERAPY 

Authorized Personnel Only 

24 


11.1 Education and training 

Training is an essential component of reducing exposure to 

hazardous drugs in occupational settings. It is the employer’s 

responsibility to ensure that workers are informed about the 

exposure control plan for their workplace. 

All workers who are potentially exposed to hazardous drugs must 

receive education on known health risks, including any potential 

reproductive hazards and, where appropriate, training on: 

•• 

Relevant techniques and procedures for safe handling 

•• 

Proper use of relevant equipment and materials 

•• 

Spill and waste disposal procedures 

•• 

Procedures for reporting known exposures and suspected health 

effects 

11.2 Written records 

All components of an exposure control plan for hazardous drugs 

should be documented, including periodic reviews. Maintaining 

records is useful for demonstrating compliance with the Regulation. 


Part 3: Task-specific 

guidelines for reducing 

exposure to hazardous 

drugs 

The following chapters provide information for making changes in the workplace at 

each stage of handling hazardous drugs. The practices that your workplace chooses to 

adopt should be based on the findings of the risk assessment, with the goal of 

minimizing worker exposure to hazardous drugs.

12. Drug shipping 

Containers or packages of hazardous drugs can potentially be a 

source of exposure to workers involved in shipping hazardous drugs 

to facilities where they are prepared or administered. This is because 

it’s possible there may already be surface contamination on the 

outside of the packaging from the manufacturing stage. Shipments 

may also be damaged during transport resulting in leaks or spills. 

Potential activities that could result in exposure include: 

•• 

Surface contamination on the exterior of shipping packaging 

•• 

Leaks or spills during transport 

Refer to Appendix 1 for references regarding surface contamination. 

Guidelines for safe work practice 

Drug suppliers and shipping companies handling hazardous drugs 

should ensure that there are appropriate procedures in place to 

protect their workers from exposure to hazardous drugs. 

Best practices for purchasing and shipping of hazardous drugs 

include: 

•• 

Sealing hazardous drugs in plastic bags or shrink wrap during 

transport 

•• 

Ensuring there are warning labels on the outside of shipping or 

transport containers containing hazardous drugs 

•• 

Using packages and packaging methods that will minimize 

breakage 


PPE that is consistent 

with the ECP must be 

used where cytotoxic 




Personal protective equipment (PPE) 

PPE must be consistent with the worker’s potential exposure and 

may include: 

•• 


•• 

A chemotherapy-tested gown 

Refer to Appendix 4 for further details on PPE. 


13. Drug receiving and storage 

Surface contamination of containers and packaging is a potential 

source of exposure for workers as they unpack and store incoming 

shipments of hazardous drugs. Facilities should communicate with 

the drug suppliers to identify hazardous drugs during shipping and 

reduce exposure for the workers transporting and receiving the drugs. 


•• 

Handling incoming shipments of hazardous drugs that may 

have surface contamination 

•• 

Opening packages containing hazardous drugs, which could 

result in the generation of particulates or aerosol 

•• 

Handling individual containers or bags of hazardous drugs that 

may have surface contamination 

•• 

Handling damaged packaging that has resulted in a leak or 

spill 

Incoming shipments may also be damaged or broken, in which 

case proper spill procedures need to be taken (refer to Chapter 21). 

13.1 Work area design 

Hazardous drugs may be received in a receiving bay or in a 

designated room or area of a pharmacy before being stored in a 

storage area. In order to minimize exposure, areas where hazardous 

drugs are received or stored should be built and organized to 

minimize exposure. 

Receiving and storage areas should: 

•• 

Be in a designated area, preferably separated from the rest of the 

facility 

•• 

Have negative pressure with respect to surrounding rooms 

30 


13.2 Equipment 

Equipment used in receiving and storage areas should, where 

possible, be designed to minimize potential exposure to hazardous 

drugs. Examples include: 

•• 

Storage shelves with fall guards, such as lipped edges or barriers 

•• 

Containers with lids for storage and transport of hazardous drugs 

•• 

Equipment that can accommodate special storage requirements, 

such as a refrigerator for drugs that require cooler temperatures 

13.3 Guidelines for safe work practice 

Best practices to eliminate and minimize the risk to hazardous drugs 

during receiving and storage include: 

•• 

Having incoming shipments checked for damage before any 

container is opened 

•• 

Implementing a procedure to clean containers before they are 

moved to storage, such as wiping the exterior with a single-use 

disposable absorbent pad and a detergent and water solution 

•• 

Limiting access to the storage area and using signs to indicate 

restricted entry to authorized personnel only 

•• 

Storing hazardous drugs inside their original packaging (for 

example, resealable bags or shrink wrap) 

•• 

Ensuring storage containers are not overfilled 

13.4 Personal protective equipment (PPE) 









may include: 

•• 


•• 


•• 

An approved and fit-tested respirator, if handling damaged 

packages containing hazardous drugs 

Refer to Appendix 4 for further details on PPE. 


14. Drug transport 

Workers who transport hazardous drugs throughout a facility may 

be exposed if they come into contact with hazardous drug surface 

contamination or a hazardous drug leak or spill. 


•• 

Handling containers or packages with hazardous drug surface 

contamination 

•• 

Handling containers or packages when there has been a leak 

or a spill 


The equipment used for transporting hazardous drugs throughout a 

facility should be designed to minimize exposure to workers 

handling hazardous drug products. This includes: 

•• 

Equipment that reduces spills, such as carts with lipped edges 

and closed, hard-sided transport boxes 

•• 

Using equipment that is easy to clean 


Best practices for transporting hazardous drugs include: 

•• 

Using resealable clear plastic bags to place hazardous drug 

products in before transport 

•• 

Using closed, hard-sided boxes to be used for transport 

throughout the facility 

•• 

Implementing procedures for safe handling of products during 

transport 










may include: 

•• 

Double chemotherapy-tested gloves 

•• 


Refer to Appendix 4 for more details on PPE. 

32 


15. Drug preparation 

A preparation room is where drugs are prepared, compounded, and 

verified before they are administered to patients. Workers may 

work directly with hazardous drugs. Care must be taken to minimize 

exposure during handling and to limit the spread of hazardous drug 

contamination. 


•• 

Compounding, diluting, or altering hazardous drug medications 

•• 

Priming administration equipment, which can generate aerosol 

or particulate contamination 

•• 

Handling, crushing, or opening oral medications 

•• 

Handling hazardous drugs while verifying before they leave the 

pharmacy, as packaging may have surface contamination 


Preparation rooms can be sterile or non-sterile, depending on the 

conditions that are required for the task being performed. A sterile 

preparation room (which may also be called a clean room) should 

not be used for compounding non-sterile preparations. 

Refer to the following resources for detailed information on clean 

room specifications: 

•• 

NAPRA “Model Standards for Pharmacy Compounding of 

Hazardous Sterile Products” 

•• 

USP Chapter “Pharmaceutical Compounding - Sterile 

Preparations” 

•• 

USP Chapter “Hazardous Drugs - Handling in Healthcare 

Settings” 

Sterile preparation rooms should: 

•• 

Be an ISO Class 7 environment, if the room contains a biological 

safety cabinet for sterile preparations 

•• 

Exhaust all air through at least one high efficiency particulate air 

(HEPA) filter before being exhausted externally from the building 

•• 

Have an ISO Class 7 anteroom through which personnel enter, 

with interlocking doors that cannot be opened at the same time 

•• 

Use pass-through hatches for the transfer of preparations out of 

the room 


•• 

Have a viewing window and an intercom system so workers can 

communicate with workers outside the room 

•• 

Have furniture and equipment made of materials that are easily 

cleaned and decontaminated, such as stainless steel 

Non-sterile preparation rooms are where hazardous drugs can be 

prepared in non-sterile conditions, such as splitting or crushing oral 

medications, repackaging medications into dosettes, preparing oral 

solutions, or preparing topical creams. 

Non-sterile preparation rooms should: 

•• 

Be kept under negative pressure with respect to surrounding rooms 

•• 

Be a separate room that is dedicated for non-sterile hazardous 

drug preparations 

•• 

Exhaust all air externally 

•• 

Use furniture and equipment made of materials that are easily 

cleaned and decontaminated, such as stainless steel 


The equipment used during the preparation of hazardous drugs 

should be selected based on their effectiveness at reducing worker 



Where preparation 

activities involving 

cytotoxic drugs take 

place at the facility, 

an approved BSC 

must be provided and 

used. See section 

6.53(1)(a)(b) of the 

Regulation. 

Biological safety cabinets 

A biological safety cabinet (BSC) is a ventilated containment 

cabinet that is designed to provide personnel, product, and 

environmental protection. 

Not all BSCs are appropriate for use with hazardous drugs. BSCs 

that are used for preparing hazardous drugs should: 

•• 

Be exhausted to the outside atmosphere to prevent recirculation 

into the preparation room 

•• 

Have exhaust and ventilation systems that operate continuously 

to ensure that no contaminants escape from the biological safety 

cabinet into the workplace 

BSCs are divided into three classes (Class I, Class II, and Class III) 

that are each designed to meet different needs depending on their 

intended use. In workplaces where both sterile and non-sterile 

preparations take place, it is best practice to have a separate BSC 

dedicated for each purpose. 

Refer to Appendix 5 for additional information on the selection of 

an appropriate BSC. 

34 



Where a BSC is used, 

it must be equipped 

with a continuous 

airflow monitoring 

device where 


present. See section 

6.53(1)(c) of the 

Regulation. 

Performance testing of BSCs 

Performance testing of the preparation room equipment should 

take place regularly. 

All BSCs used for hazardous drugs should be equipped with a 

continuous airflow monitoring device to ensure adequate airflow 

and performance of the BSC before it is used to prepare hazardous 

drugs. Workers who use the BSC should regularly document the 

readings on the monitoring device and be able to recognize when 

the readings indicate a malfunctioning BSC, as well as appropriate 

procedures to follow if this occurs. Safe work procedures must be 

developed to ensure worker protection when a BSC is turned off. 

BSCs must be regularly tested and certified to ensure that they are 

performing properly following the manufacturer’s specifications 

and the requirements of the Regulation. 

Closed-system transfer devices 

Closed-system transfer devices (CSTDs) are designed to contain 

hazardous drugs and minimize potential exposure when transferring 

hazardous drugs between containers or pieces of equipment. 

It is important to note that a CSTD is not a substitute for compounding 

preparations inside a BSC. When a CSTD is used during the 

preparation of hazardous drugs, it should always be inside a BSC. 

Several studies have demonstrated that the use of a CSTD in 

addition to a BSC reduces surface contamination of hazardous 

drugs in the workplace. Strong consideration should be made to 

using a CSTD for transferring hazardous drugs between containers 

whenever practicable. 


Locking fittings which 

cannot accidentally 

disconnect must be 

must be used where 




Regulation. 

Additional equipment 

Many different types of equipment and supplies are used in the 

preparation of hazardous drugs. Further examples include: 

•• 

Fittings that prevent accidental disconnection, such as luer lock 

fittings 

•• 

Appropriate needleless systems or safety engineered needles 

that reduce the risk of workers getting a percutaneous exposure 

•• 

Filtered venting devices, such as chemotherapy dispensing pins 

and chemotherapy vents, which can minimize the accidental 

release of hazardous drugs when reconstituting or withdrawing 

from a vial 

Refer to Appendix 6 for information on medical equipment that 

may be appropriate for use with hazardous drugs. 



Safety engineered 

needles or needleless 

systems must be 

used when caring 

for or treating a 

person. This applies 

to all hazardous 

drugs, including 

cytotoxic drugs. See 


Regulation. 


Best practices for the preparation of hazardous drugs include: 

•• 

Obtaining hazardous drugs from the supplier in a form that is 

ready to administer 

•• 

Using safety-engineered needles that do not produce spray 

when activated 

•• 

Using CSTDs 

•• 

Using disposable plastic syringes 

•• 

Using an approved BSC for preparations of hazardous drugs 

(where possible, the BSC should be designated for either sterile 

or non-sterile compounding) 

•• 

Planning tasks to avoid unnecessary leaving and re-entering the 

preparation room 

•• 

Limiting access to the preparation room to workers trained to 

work in the room (such as pharmacy and housekeeping staff) 

•• 

Limiting equipment and materials in a BSC to those required to 

prepare one dose for one patient, to avoid overcrowding and 

mixing up drugs 

•• 

Implementing procedures for priming equipment with a 

hazardous drug solution in a BSC (see the next chapter for 

priming with a non-hazardous drug solution) 

•• 

Implementing procedures to have all alterations of hazardous 

drug tablets or capsules (such as cutting, splitting, and crushing) 

inside an approved BSC 

•• 

Not using automated unit-dose packaging machines or 

automated counting machines with tablet or capsule forms of 


•• 

Implementing procedures to reduce contamination of containers 

and IV bags after they leave the BSC, such as cleaning with a 

soap-moistened towel and placing the product in a clear 

resealable bag 

15.4 Cleaning 

The preparation room should also be cleaned regularly as part of 

regular housekeeping and throughout the work day. This includes: 

•• 

Regular cleaning of the interior of the BSC 

•• 

Cleaning and decontaminating of the preparation room, from 

cleanest areas to the most contaminated (for example, from the 

walls and then inwards to the BSC) 

•• 

Cleaning, disinfecting, and decontaminating the entire interior of 

the cabinet after a non-sterile preparation (this should be done 

before a sterile preparation can be performed in the same BSC) 

36 


Refer to Appendix 7 for more information on the selection of 

cleaning agents. 










may include: 

•• 


•• 


•• 

Shoe covers 

•• 

Eye and face protection 

•• 

An approved and fit-tested respirator 



16. Drug administration 

Administration of hazardous drugs can take many forms, such as IV 

therapy, inhalation therapy, surgical procedures, injections, oral, 

and topical medications. 


•• 

Using administration equipment that may leak or spill, such as 

IV equipment 

•• 

Cutting or crushing tablets at the point of administration 

•• 

Directly handling medications, such as oral or topical treatments 

•• 

Removing air or priming equipment such as syringes 

•• 

Exposure to blood or body fluids during the precautionary 

period 


Hazardous drugs are administered in treatment areas in a number 

of different settings. The design of treatment areas should reflect 

the findings of the risk assessment. 

Treatment areas where hazardous drugs are administered: 

•• 

Should be kept under neutral or negative air pressure to the 

surrounding rooms, where possible 

•• 

Should use surfaces that are easy to clean, such as stainless steel, 

where possible 

•• 

Should keep any rest areas for workers or visitors isolated from 

any administration areas 


All activities involving 

the administration 

of medication to 

a person must be 

done using a safety 

engineered medical 

sharp or a needleless 

system. See section 


16.2 Drug administration equipment 

The selection of appropriate equipment for the administration of 

hazardous drugs can help minimize the risk of exposure to workers. 

All activities involving the administration of medication to a person 

must be done with safety-engineered medical sharps or a 

needleless system, where clinically appropriate. 

Equipment used for the administration of hazardous drugs includes: 

•• 

Closed-system transfer devices (CSTDs) designed for the 

administration of hazardous drugs 

•• 

Safety-engineered needles 

38 


•• 

Filtered venting devices, such as chemotherapy-dispensing pins 

and chemotherapy vents 

•• 

Administration equipment, such as IV pumps and CADD pumps 

Refer to Appendix 6 for information on how to select medical 

equipment that is appropriate for use with hazardous drugs. 



All priming of 

administration sets 

with a cytotoxic drug 


in an approved BSC. 


the Regulation 

Best practices for the administration of hazardous drugs include: 

•• 

Avoiding priming IVs with a hazardous drug solution at the point 

of administration (this should be done as part of the preparation 

step in an approved BSC) 

•• 

Avoiding altering oral medications, such as crushing or cutting, at 

the point of administration (this should be done as part of the 

preparation step in an approved BSC) 

•• 

Where possible, avoiding contact with oral medications during 

administration by using medication cups, unit-dose packaging 

from the manufacturer, or having patients administer their own 

medication 

•• 

If priming of administration sets cannot be done as part of the 

preparation step, implementing procedures so that priming is 

performed with compatible dilutant and the drug is added afterwards 

•• 

Using CSTDs for administration activities, including withdrawing 

and injecting hazardous drugs from syringes and IV systems 

•• 

Using disposable, absorbent pads to be placed under the patient 

where administration is occurring 

•• 

Using bandages that can be applied over an area where a topical 

medication has been applied to avoid spreading contamination 

to clothing or bedsheets 

•• 

Limiting access to administration areas (this is extremely important 

for some administration forms, particularly aerosolization therapy, 

and only the patient should be in the room where treatment is 

taking place) 

•• 

Implementing procedures for proper disposal of administration 

equipment, such as flushing IV tubing with a dilutant before 

disconnecting or discarding tubing immediately after use as 

hazardous waste 

16.4 Cleaning 

There should be regular cleaning of administration areas. The 

administration area should have a set of cleaning equipment 

dedicated for that area. 


Work areas, such as trays, carts, tabletops, chairs, and beds where 

hazardous drugs are administered, should be cleaned daily. 

Refer to Appendix 7 for more information on the selection of 

cleaning agents. 

16.5 Considerations for home care 

Administering hazardous drugs in home care settings poses 

additional challenges because there is less ability to change the 

physical work environment. 

Where possible, an initial assessment of the home should be done 

to determine that there are appropriate facilities for the activities 

that will take place in the home. This may include: 

•• 

Running water to allow for hand washing 

•• 

A properly functioning toilet 

•• 

Windows that can be opened to provide ventilation 

The guidelines for safe work practice in administration settings 

discussed in the previous sections may also be applied in the home 

care setting, where relevant. Additional best practices for 

administration in the home include: 

•• 

As much as possible, avoiding any alteration of hazardous drugs 

in the home (activities such as cutting or crushing oral 

medications and dissolving powders into solution should be 

done by pharmacy staff in a BSC) 

•• 

Providing the patient with instructions on: 

–– 

How to use administration equipment, such as electronic 

diffusion devices 

–– 

Safe handling precautions for bodily fluids during the 

precautionary period for their treatment, including 

recommendations for the equipment and PPE required 

–– 

How to safely dispose of hazardous drug waste and 

contaminated medical sharps 

The precautionary period is the period of time that a patient 

excretes hazardous drugs after their treatment. For most treatment 

protocols this is 48 hours but may be up to seven days. Refer to 

the treatment protocol to determine the precautionary period for 

each patient. 

40 











may include: 

•• 


•• 


•• 

Face and eye protection 



17. Veterinary practice 


To reduce exposure, 

appropriate 

treatment controls 

resulting from a risk 

assessment must 

be applied where 


present. See sections 

5.55 and 6.43 of the 

Regulation. 

Hazardous drugs are increasingly being used to treat animals, 

ranging from cats and dogs to horses. Regardless of whether the 

animal is being treated at a clinic or in the community (for example, 

a barn), there should be a risk assessment to determine appropriate 

controls for reducing worker exposure to hazardous drugs. 


•• 

Administering hazardous drugs to animal patients 

•• 

Holding the animal during treatment 

•• 

Cleaning the treatment area, cages, or kennels 


In order to minimize exposure, veterinary settings where hazardous 

drugs are administered should have appropriate controls reflecting 

the results of the risk assessment. This may include: 

•• 

Having a preparation room as described in Chapter 15 if any 

preparation activities take place at the facility 

•• 

Having a separate storage area for hazardous drugs, away from 

other drugs and from animal or worker food and drink 

•• 

Having one room dedicated for the administration of hazardous 

drugs 

•• 

Having cages, kennels, or stalls dedicated for animals that are 

receiving or have recently received chemotherapy 

42 






place at the facility, an 

approved BSC must 

be provided and used. 







device where 




Regulation. 


Appropriate equipment for using hazardous drugs in veterinary 

practice may include: 

•• 

An approved BSC, if any preparation activities take place at the 

facility. 

•• 

Safety-engineered sharps or needleless systems for the 

administration of hazardous drugs. Although not a regulatory 

requirement in veterinary practice, these reduce the risk of 

exposure to workers. 

•• 

Equipment dedicated for use with animals receiving hazardous 

drugs. 

Refer to Appendix 6 for information on how to select equipment 

that is appropriate for use with hazardous drugs. 


Best practices for the use of hazardous drugs in veterinary settings 

include: 

•• 

Where possible, purchasing hazardous drugs in a form that is ready 

to administer, to avoid preparation activities at the practice facility 

•• 

Where possible, referring animals to specialized treatment centres 

•• 

Identifying animals who have received hazardous drugs, such as 

by placing signs on cages or kennels 

•• 

Prohibiting the use of pressure washers to clean cages, kennels, 

and stalls of animals being treated with hazardous drugs to 

minimize the spread of aerosolized contamination 

•• 

Supplying disposable towels for cleaning cages, kennels, and 

animals, where practicable 

Animals who have received hazardous drugs should also be cared 

for with safe handling precautions after their treatment (see Chapter 

18, “Patient Care”). 

17.4 Cleaning 

Cleaning and decontamination of the veterinary practice facility 

should take place regularly to reduce contamination with hazardous 

drug residues. This includes: 

•• 

Regular cleaning of animal excreta 

•• 

Regular cleaning and decontamination of the treatment area 

•• 

Gently hosing down cages and kennels to avoid producing 

aerosolized contamination 











may include: 

•• 


•• 


•• 


•• 



44 


18. Patient care 

Providing personal care for patients receiving hazardous drugs 

requires additional precautions. Body fluids have been shown to 

contain hazardous drugs for a set amount of time known as the 

precautionary period, which is the period of time that safe handling 

precautions are required when caring for the patient. 


•• 

Handling patient bodily fluids from a patient who has received 


•• 

Bathing the patient 

•• 

Handling contaminated bedding or laundry 

•• 

Assisting with toileting, especially flushing toilets 

•• 

Cleaning the patient’s room, washroom, or home 


The design of the patient care area must reflect the results of a risk 

assessment to reduce exposure to hazardous drugs. 

In general, care areas where patients are receiving or have received 

hazardous drugs should: 

•• 

Be isolated from other patient care areas, where possible 

•• 

Have dedicated washroom facilities for patients who have 

received hazardous drugs 

•• 

Have appropriate laundry services 


Equipment used for caring for patients within the precautionary 

period includes: 

•• 

Bed pans that are disposable, when possible 

•• 

Carts and trays that are easy to clean and dedicated for use with 

patients who have received hazardous drugs 

Refer to Appendix 6 for information on how to select medical 

equipment that is appropriate for use with hazardous drugs. 



Employers must have 

procedures for the 

disposal of body 

fluids from patients 

who have been treated 

with cytotoxic drugs. 

See sections 6.48 and 



Best practices for the care of patients receiving or who have 

received hazardous drugs include: 

•• 

Implementing safe handling procedures for handling body fluids 

of patients within the precautionary period, such as covering 

toilets and double flushing 

•• 

Implementing safe handling procedures for handling laundry 

from patients within the precautionary period, such as avoiding 

shaking, folding the bedding so any contamination is trapped in 

the centre, and placing laundry in a plastic bag 

•• 

Where possible, discarding laundry or bedding that is heavily 

contaminated by body fluids, or alternatively washing separately 

once before being added to other facility laundry 

•• 

On top of regular charting requirements, documenting the length 

of the precautionary period for the patient as per the treatment 

protocol 

•• 

Ensuring workers review patient history before providing care 

When patients are being cared for after treatment at home, either 

by a health care worker or their family, they should be provided 

with the instructions described in Chapter 15. 

18.4 Cleaning 

Patient care areas should be cleaned and decontaminated regularly. 

This includes: 

•• 

Cleaning washrooms of patients receiving hazardous drugs regularly 

•• 

Cleaning up spills of patient body fluids immediately 










may include: 

•• 


•• 

A chemotherapy-tested gown, if there is a risk of splashing of 

body fluids 

•• 

Face and eye protection, if there is a risk of splashing of body fluids 

•• 

An approved and fit-tested respirator, if there is a risk of inhaling 

aerosols or particulates 


46 


19. Cleaning 

Many workplaces may have contract workers who are responsible 

for the majority of cleaning activities. If this is the case, it is 

essential that there is coordination with the contracting company to 

develop procedures to minimize hazardous drug contamination 

throughout the workplace. 


•• 

Contact with hazardous drug surface contamination 

•• 

Contact with body fluids or waste 

•• 

Splashing of cleaning solutions used to clean hazardous drugs 


Best practices for cleaning activities in areas with hazardous drug 

contamination include: 

•• 

Providing training on hazardous drugs for workers, including 

potential routes of exposure and how to minimize exposure for 

themselves 

•• 

Using cleaning supplies designated for areas known to have 

potentially high hazardous drug contamination, such as 

pharmacies 

•• 

Changing routine cleaning practices to minimize hazardous drug 

contamination 

Refer to Appendix 7 for information on how to select appropriate 

cleaning agents for use with hazardous drugs. 










may include: 

•• 


•• 


•• 

Face and eye protection, 

•• 




20. Waste disposal 


The employer must 

develop safe work 

procedures for 

handling cytotoxic 

drug waste. See 

sections 6.48 

and 6.57 of the 

Regulation. 

Hazardous drug waste is a potential source of exposure to 

hazardous drugs. The employer should develop safe work 

procedures for safely disposing of hazardous drug waste. 

Hazardous drug waste may include: 

•• 

Hazardous drugs that are to be disposed of 

•• 

Disposable equipment used to administer hazardous drugs, such 

as syringes, needles, or IV tubing 

•• 

Disposable PPE used for protection against exposure to 


•• 

Bodily fluids, such as vomit, stool, urine, and sweat, from 

patients who have recently received hazardous drugs 

•• 

Disposable materials contaminated with body fluids from 

patients who are within the precautionary period 


•• 

Disposing of hazardous drug-related waste, if it is contaminated 

or leaking 

•• 

Handling hazardous drug waste containers, which may have 

surface contamination 


If hazardous drug waste is stored at the workplace before it is taken 

to be disposed of, it should be stored with appropriate precautions, 

as determined by the risk assessment. This includes: 

•• 

Storing hazardous drug waste in a cool, locked, and ventilated 

area until it is transported out of the facility 

•• 

Isolating the storage area for hazardous drug waste from other 

areas of the workplace as much as possible 

•• 

Storing in a manner to prevent leaks and spills, such as by having 

shelves with lipped edges 

•• 

Using materials that are easy to clean, such as stainless steel 

48 



A hazardous drug 

waste container or 

bag must be provided 






Hazardous drug waste should be collected in a hazardous drug 

waste container. 

A hazardous drug waste container: 

•• 

Must be leak-proof and puncture resistant 

•• 

Must be designated for use with hazardous drugs 

•• 

Should be easily identifiable as designated for hazardous drugs, 

such as by using a uniform colour throughout the workplace 

A bag used for disposal of soft materials (for example, laundry, 

gloves, or gowns) contaminated with hazardous drugs: 

•• 

Should be leak-proof 

•• 

Should be made of thick, leak-proof plastic 

•• 

Should be easily identifiable 

•• 

Must be appropriately labelled with a hazardous drug warning 

All areas where there is potential for hazardous drug waste should 

have a hazardous drug waste container. These areas can be 

determined as part of a risk assessment. 

Hazardous drug waste containers and bags should also be provided 

to patients and animal owners who are receiving hazardous drugs 

or being cared for at home. 


For information on 

hazardous waste 

disposal in B.C., visit 

www.hazwastebc.com. 

Best practices for disposal of hazardous drug waste include: 

•• 

Coordinating of hazardous drug communication with external 

waste-collection companies to reduce worker exposure 

•• 

Sending hazardous drug waste for disposal by a certified 

hazardous waste organization and in accordance with local 

regulations 

•• 

Having hazardous drug waste containers collected and 

transported throughout a facility only by workers trained to do so 

•• 

Arranging for the collection of hazardous drug waste containers 

from patients homes 

•• 

Implementing procedures to reduce leaks from hazardous waste 

containers, such as by placing contaminated items in double 

plastic bags before placing in a hazardous drug waste container 

Refer to CSA Standard Z317.10-09 Handling of Waste Materials in 

Health Care Facilities and Veterinary Health Care Facilities for 

more information on hazardous drug waste. 











may include: 

•• 


•• 


•• 

Face and eye protection, if there is a risk of splashing 

•• 

An approved and fit-tested respirator if there is a risk of inhaling 

aerosols or particulate 


50 


21. Spill response 


Employers must 

develop emergency 

procedures for spills 

of cytotoxic drugs. 



Employers must develop emergency procedures that address spills 

of hazardous drugs. Signs detailing spill response procedures 

should be posted in all relevant areas of the workplace. 


•• 

Contact with a leak or spill 

•• 

Inhalation of aerosols, vapours, or particulates released as the 

result of a spill 

•• 

Contact with contaminated cleaning supplies 


Spill kits must be 

provided where 



section 6.58(2) of the 

Regulation. 


Best practices for hazardous drug spill response include: 

•• 

Supplying a spill kit in all areas where hazardous drugs are 

handled 

•• 

Placing personnel decontamination kits in all areas where 

hazardous drugs are handled 

•• 

Providing home care workers who are administering hazardous 

drugs with the tools they might need to safely clean up a spill 

•• 

Providing regular training on emergency spill procedures 

•• 

Allowing only workers trained and authorized to clean spills to do so 

•• 

Training workers not authorized to clean a large spill on how to 

notify other workers and block off an area 

•• 

Ensuring all spill cleanup supplies are discarded as hazardous waste 

Refer to Appendix 8 for an example of what should be included in a 

spill kit. 










may include: 

•• 


•• 


•• 

Face and eye protection, if there is a risk of splashing 

•• 

An approved and fit-tested respirator, if there is a risk of inhaling 

aerosols or particulate 



Appendices

Appendix 1: References and resources 

Health effects of occupational exposure 

Connor, T.H, Lawson, C.C, Polovich, M, McDiarmid, M.A. 

Reproductive health risks associated with occupational exposures 

to antineoplastic drugs in health care settings — A review of the 

evidence. J Occup Environ Med 56 (2014):901-910. 

Fransman, W., Kager, H., Meijster, T., Heederick, D., Kromhout, H., 

Portengen, L., Blaauboer, BJ. Leukemia from dermal exposure to 

cyclophosphamide among nurses in the netherlands: Quantitative 

assessment of the risk. Ann Occup Hyg (2014): 1-12. doi:10.1093/ 

annhyg/met077. 

Hemminki K, Kyyrönen P, Lindbohm M-L. Spontaneous abortions 

and malformations in the offspring of nurses exposed to anesthetic 

gases, cytostatic drugs, and other potential hazards in hospitals, 

based on registered information of outcome. J Epidemol 

Community Health 39 (1985): 141-147. 

Hon, C., Teschke, K., Shen, H., Demers, PA., Venners, S. 

Antineoplastic drug contamination in the urine of Canadian 

healthcare workers. Int Arch Occup Environ Health (2015) DOI 

10.1007/s00420-015-1026-1. 

Ratner, PA., Spinelli, JJ., Beking, K., Lorenzi, M., Chow, Y., Teschke, 

K., Le, ND., Gallagher, RP., Dimich-Ward, H. Cancer incidence and 

adverse pregnancy outcome in registered nurses potentially 

exposed to antineoplastic drugs. BMC Nurs 9:15 (2010). 

Selevan SG, Lindbohm ML, Hornung RW, Hemminki K. A study of 

occupational exposure to antineoplastic drugs and fetal loss in 

nurses. N Engl J Med 313 (1985): 1173–78. 

Sessink PJM, Cerna M, Rossner P, Pastorkova A, Bavarova H, 

Frankova K, Anzion RB, Bos RP. Urinary cyclophosphamide 

excretion and chromosomal aberrations in peripheral blood 

lymphocytes after occupational exposure to antineoplastic agents. 

Mutat Res 309.2 (1994): 193-199. 

Stücker I, Caliiard J-F, Collin R, Gout M, Poyen D, Hémon, D. Risk 

of spontaneous abortion among nurses handling antineoplastic 

drugs. Scand J Work Environ Health 16 (1990): 102–107. 


Valanis B, Vollmer WM, Steele P. Occupational exposure to 

antineoplastic agents: Self-reported miscarriages and stillbirths among 

nurses and pharmacists. J Occup Environ Med 41 (1999): 632–638. 

Routes of occupational exposure 

Connor T.H. Permeability of nitrile rubber, latex, polyurethane, and 

neoprene gloves to 18 antineoplastic drugs. Am J Health Syst 

Pharm 56.23 (1999): 2450-2453. 

Connor T.H, DeBord, D.G, Pretty, J.R, Oliver, M.S, Roth, T.S, Lees, 

P.S.J, Krieg, E.F. Evaluation of antineoplastic drug exposure of 

health care workers at three university-based US cancer centers. 

American C Occ Env Med 52.10 (2010):1019-1027. 

Connor T.H, Shults, M, Fraser, M. Determination of the vaporization 

of solutions of mutagenic antineoplastic agents at 23 and 37˚C 

using a desiccators technique. Mutat Res 470 (2000): 85-92. 

Odraska, P., Mazaurova, E., Dolezalova, L., Blaha, L. In vitro evaluation 

of the permeation of cytotoxic drugs through reconstructed human 

epidermis and oral epithelium. Klin Onkol 24.3 (2011): 195-202. 

Turci R, Minoia C, Sottani C, Coghi R, Severi P, Castriotta C, et al. 

Occupational exposure to antineoplastic drugs in seven Italian 

hospitals: The effect of quality assurance and adherence to 

guidelines. J Oncol Pharm Pract. 17.4 (2011): 320-332. 

Surface contamination 

Connor T.H., Sessink P.J., Harrison B.R., Pretty J.R., Peters B.G., 

Alfaro R.M., Bilos A., Beckmann G., Bing M.R., Anderson L.M., 

Dechristoforo R. Surface contamination of chemotherapy drug vials 

and evaluation of new vial-cleaning techniques: results of three 

studies. Am J Health Syst Pharm 62.5 (2005):475-84. 

Hedmer M, Tinnerberg H, Axmon A, Joensson BAG. Environmental 

and biological monitoring of antineoplastic drugs in four 

workplaces in a Swedish hospital. Int Arch Occup Environ Health 

81.7 (2008): 899–911. 

Hon, C., Teschke, K., Chu, W., Demers, P., & Venners, S. 

Antineoplastic drug contamination of surfaces throughout the 

hospital medication system in canadian hospitals. J Occ Env Hyg 

10.7 (2013): 374-383 DOI: 10:1080/15459624.2013.789743. 

56 


Hon, C., Venners, S., Demers, P., Chua, P., Astrakianakis, G., Chu, 

W., Ensom, R., & Teschke, K. Healthcare workers and antineoplastic 

drugs: Identifying the determinants of exposure and current 

challenges to reducing exposure. (2012). Focus on Tomorrow. 

Closed-system transfer devices 

Sessink PJM, Trahan J and Coyne JW. Reduction in surface 

contamination with cyclophosphamide in 30 hospital pharmacies 

following implementation of a closed-system drug transfer device. 

Hosp Pharm 48 (2013):204-212. 

Yoshida J, Tei G, Mochizuki C, Masu Y, Koda S and Kumagai S. Use 

of a closed system device to reduce occupational contamination 

and exposure to antineoplastic drugs in the hospital work 

environment. Ann Occup Hyg 53 (2009):153-160. 

Cleaning and decontamination 

Barzan, C. Towards the Reduction of Occupational Exposure to 

Cytotoxic Drugs, 2010. Thesis dissertation. 

Lamerie, T.Q, Nussbaumer, S, Décaudin, B, Fleury-Souverain, S, 

Goossens, J.F, Bonnabry, P, Odou, P. Evaluation of decontamination 

efficacy of cleaning solutions on stainless steel and glass surfaces 

contaminated by 10 antineoplastic agents. Ann Occup Hyg 57.4 

(2013):456-469. DOI: 10.1093/annhyg/mes087. 

Best practice resources 

These resources were reviewed to develop the best practices 

throughout this book. 

American Society of Health System Pharmacists (ASHP). 2004. 

Guidelines on Handling Hazardous Drugs. 

Association paritaire pour la santé et la sécurité du travail du 

secteur affaires socials (ASSTSAS) [Joint Sector-based Association 

for Health and Occupational Safety for the Social Sector]. 2007. 

Prevention Guide: Safe Handling of Hazardous Drugs. 

BC Cancer Agency (BCCA). 2012. Safe Handling of Hazardous 

Drugs- Module 1. 

Canadian Association of Pharmacy in Oncology (CAPhO). 2009. 

Standards of Practice for Oncology Practice in Canada. 


Chaffee, B, Armitstead, J, Benjamin, B, Cotugno, M, Forrey, R, 

Hintzen, B, Pfeiffenberger, T, & Stevenson, J. Guidelines for the 

safe handling of hazardous drugs: Consensus recommendations. 

Am J Health-Syst Pharm 67 (2010): 1254-1546. 

International Society of Oncology Pharmacy Practitioners (ISOPP). 

2007. Standards of Practice – Safe Handling of Cytotoxics. 

National Institute for Occupational Safety and Health (NIOSH). 2014. 

NIOSH List of Antineoplastic and Other Hazardous Drugs in 

Healthcare Settings, 2014. Centers for Disease Control and 

Prevention. 

National Institute for Occupational Safety and Health (NIOSH). 

2010. Safe Handling of Hazardous Drugs for Veterinary Workers. 

Workplace Solutions. 

National Institute for Occupational Safety and Health (NIOSH). 

2004. Preventing Occupational Exposures to Antineoplastics and 

Other Hazardous Drugs in Health Care Settings. NIOSH Alert. 

Occupational Health and Safety Administration (OSHA). 1999. 

Technical Manual Section VI Chapter 2– Controlling Occupational 

Exposure to Hazardous Drugs. 

WorkSafe Victoria. 2013. Handling cytotoxic drugs in the 

workplace: Handling health and safety risks associated with 

handling cytotoxic drugs in the healthcare industry. 

In-text resources 

These are additional resources that are mentioned throughout the 

book. 

ASTM D6978 – 05(2013). American Society for Testing and 

Materials: Standard Practice for Assessment of Resistance of 

Medical Gloves to Permeation by Chemotherapy Gloves. 

Canadian Biosafety Standards and Guidelines (CBSG) First Edition: 

http://canadianbiosafetystandards.collaboration.gc.ca/cbsg-nldcb/ 

index-eng.php. 

Canadian Pharmacists Association (CPhA): Compendium of 

Pharmaceuticals and Specialties (CPS). 

Canadian Standards Association (CSA): Z317.10-09 Handling of 

Waste Materials in Health Care Facilities and Veterinary Health 

Care Facilities. 

58 


NIOSH: Hazardous Drugs webpage http://www/cdc/gov/niosh/ 

docket/archive/docket233.html. 

NIOSH: Antineoplastic and Hazardous Drugs List http://www.cdc. 

gov/niosh/topics/hazdrug/#a. 

Health Canada: Drug Product Database http://www.hc-sc.gc.ca/ 

dhp-mps/prodpharma/databasdon/index-eng.php. 

National Association of Pharmacy Regulatory Authorities (NAPRA): 

Model Standards for Pharmacy Compounding of Hazardous Sterile 

Products. 

United States Pharmacopeia (USP): Chapter Pharmaceutical 

Compounding – Nonsterile Preparations. 

United States Pharmacopeia (USP): Chapter Pharmaceutical 

Compounding – Sterile Preparations. 

United States Pharmacopeia (USP): Chapter Hazardous 

Drugs – Handling in Healthcare Settings (Draft). 

WorkSafeBC: Breathe Safer: How to Use Respirators Safely and 

Start a Respirator Program http://www.worksafebc.com/ 

publications/high_resolution_publications/assets/pdf/bk75.pdf. 

WorkSafeBC: How to Implement a Formal Occupational Health 

and Safety Program http://www.worksafebc.com/publications/ 

health_and_safety/by_topic/assets/pdf/howtoimplement_ohs.pdf. 


Appendix 2: Glossary 

Administrative 

controls 

Antineoplastic 

Biological safety 

cabinet (BSC) 

Biomarkers 

Chemical 

cartridge 

Chemotherapy 

gloves 

Clean room 

Closed-system 

transfer device 

(CSTD) 

Controls 

Cytotoxic drugs 

Engineering 

controls 

Methods that reduce exposure to a hazardous substance by changing work 

procedures and the organization of the workplace. 

An agent that acts to prevent, inhibit, or prevent the development of a 

neoplasm (a tumour), and which is most often used in the treatment of 

cancer. 

A ventilated containment cabinet that provides an ISO Class 5 environment 

for compounding products. 

Measureable, biological signs that indicate exposure to a substance or 

development of a disease. For example, this could be a metabolite of a 

chemical or a predicted change in normal body functioning. 

A cartridge that can be added to an elastomeric respirator that is designed 

to trap gases or vapours from the air a worker breathes. These cartridges 

contain chemical compounds that react with specific contaminants so they 

are removed from the air and must be replaced following a specific 

schedule outlined by the manufacturer. 

Gloves that are designed specifically for handling hazardous drugs. They 

should be tested and approved according to the American Society for 

Testing and Materials (ASTM) standard for permeability to hazardous drugs. 

A preparation room where sterile drugs are prepared. It is “clean” because 

it controls the level of contamination by using ventilation and air flow to 

remove non-sterile air. 

A device that completely contains a substance it is carrying, by preventing 

leaks, airborne particulates, and vapours from escaping. 

Methods of protecting against hazards. In the case of hazardous drugs, 

they remove or minimize the risk of exposure to workers. 

Drugs that act to treat disease by killing cells. They are a subset of 

hazardous drugs and are specifically covered under the Regulation. 

See the “About this Book” section for a detailed definition. 

Methods of minimizing exposure by physically changing the work 

environment to contain the source of exposure. 

60 


Environmental 

monitoring 

Exposure 

control plan 

Food and 

Drugs Act 

Genotoxic 

Hazardous 

drugs 

Hazardous 

waste container 

High efficiency 

particulate air 

(HEPA) 

ISO Class 7 

Luer lock 

Mutagenic 

Oncogenic 

The use of analytic techniques to measure contamination of an 

environment over a period of time. In the case of hazardous drugs, this is 

useful for identifying areas with higher amounts of contamination and 

determining whether current or introduced controls are effective at 

reducing the levels of hazardous drugs in the work environment. 

A requirement in the Regulation that details how the workplace will 

minimize exposure to hazardous drugs. Employers must develop and 

implement an exposure control plan if their workers may be exposed to 

cytotoxic drugs. 

Canadian federal legislation that regulates the use of cosmetics, drugs, and 

food. Substances under this act are not required to provide supplier labels 

and SDSs as described in WHMIS. 

A substance that can damage the genetic material of cells, which causes 

mutations to arise. 

As defined by NIOSH, a group of drugs that have know carcinogenicity, 

teratogenicity, reproductive toxicity, organ toxicity, or genotoxicity in 

humans or animals (or a new drug that mimics an existing drug with one of 

these characteristics). Examples include drugs used for treatment of 

cancer, hormone treatments, and diluted forms of these drugs used to 

treat a range of illnesses. 

A container that is designated to be used only for hazardous waste. These 

must be clearly labelled as meant for hazardous waste and are generally a 

different colour than other waste containers in the workplace so that they 

can be easily identified. 

A specialized filter that traps particulate matter. They are used to filter air 

that is entering a biological safety cabinet as well as air that is exhausted 

externally. They may also be used in local ventilation systems for specific 

rooms in a workplace. 

A measure of air quality using the ISO classification system, which is based 

on how much particulate is present per cubic metre of air. The classes go 

from what is considered the “dirtiest” air (ISO Class 9) to what is the 

“cleanest” air (ISO Class 1). 

A fitting for medical instruments that is designed to prevent leaking. 

A substance that causes mutations to occur in the genetic material of cells. 

Describes a substance that has the ability to cause a (malignant) cancer. 


Percutaneous 

Personal protective 

equipment (PPE) 

Permeability 

Precautionary 

period 

Priming 

Protective 

reassignment 

Risk assessment 

Safety-engineered 

medical sharp 

Substitution 

Surface 

contamination 

Surface wipe 

sampling 

A cut or puncture that breaks through the skin. 

A method of reducing occupational exposure to hazardous substances that 

involves the worker wearing or using specialized clothing or equipment. 

The ability of a substance to pass through a barrier. 

The amount of time after the administration of hazardous drugs when 

patient bodily fluids should be treated as hazardous and handled with safe 

handling precautions. The exact time period is determined by the 

treatment protocol for the drugs being administered, but most often it is 

48 hours. 

Running of fluid through tubing to remove air. 

Placing a worker in a role that is different than what he or she normally 

performs in order to reduce exposure to reproductive toxins. 

The process of examining the workplace in order to understand where 

workers are exposed to a hazard. It is the foundation of an exposure 

control plan. 

A medical sharp with a built-in safety feature or mechanism that eliminates 

or minimizes the risk of accidental parenteral contact while or after the 

sharp is used (for example, using a retracting mechanism or blunt tip). 

A control measure used to minimize a hazard by replacing a substance or 

process with one that is less hazardous. 

Refers to residues of hazardous drugs that are deposited on a surface. 

A method of quantifying hazardous drug surface contamination by 

collecting hazardous drug residues on a wipe. 

62 


Appendix 3: 

Monitoring the workplace environment 

Environmental monitoring, when used, should be carried out: 

•• 

Before implementing controls 

•• 

After any changes (for example, new equipment, new drugs, or 

same drugs in a different format) that could affect hazardous 

drug contamination 

•• 

After a major exposure event, such as a large spill 

•• 

Periodically in areas of concern 

Environmental monitoring should also include the following: 

•• 

Compare with records of past environmental measurements 

(suggested time period is at least five years, but longer may be 

useful for research purposes). 

•• 

Involve workers by asking for suggestions on where sampling 

should take place and informing them of the results of any 

monitoring activities. 


Site of handling 

Receiving/unpacking areas 

Storage areas 

Preparation areas 

Treatment areas 

Other areas 

Suggested sampling areas 

•• 

Unpacking table 

•• 

Floors 

•• 

Exterior of drug containers 

•• 

Work table 

•• 

Storage shelves 

•• 

Cart 

•• 

Cabinet work surface 

•• 

Floor near cabinet 

•• 

Technician’s chair 

•• 

Product verification counter 

•• 

Exterior of drug bags 

•• 

Door handle 

•• 

Counter used for priming/preparing equipment 

•• 

Arms of chairs 

•• 

Floor near administration area 

•• 

Hazardous drug waste containers 

•• 

Patient waiting room 

•• 

Equipment storage areas 

Recommended sampling sites for an environmental monitoring program for hazardous drugs, 

adapted from ASSTSAS Prevention Guide – Safe Handling of Hazardous Drugs. Refer to this 

guide for more information on implementing an environmental monitoring program. 

64 


Appendix 4: 

Personal protective equipment (PPE) 






This may include: 

•• 

Gloves designed 

for use with 


•• 

Gowns that are 

moisture resistant 

with long sleeves 

and tight-fitted 

cuffs 

•• 

Respirators 

•• 

Face and eye 

protection 

See section 

6.55(2)(a) to (d) 

Also, see sections 

8.40 and 8.41 of the 

Regulation for the 

requirements around 

the use of respirators. 

The specific PPE that is required for each task in the workplace is 

determined by a risk assessment. Workers should refer to the safe 

work procedures at their workplace for determining what types of 

PPE they are required to wear when handling hazardous drugs. 

It is the employer’s responsibility to provide appropriate PPE and 

training on its correct use and disposal. Workers are responsible for 

wearing supplied PPE when it is needed. 

If the PPE is disposable, such as chemotherapy gloves and 

chemotherapy gowns, then once it’s been used for hazardous drugs 

it must be discarded as hazardous drug waste. 


Chemotherapy-tested gloves must be worn whenever hazardous 

drugs or potentially contaminated objects are handled. 

Chemotherapy gloves should meet the requirements of ASTM 

Standard 6978-05 Standard Practice for Assessment of Resistance 

of Medical Gloves to Permeation by Chemotherapy Gloves. 

Chemotherapy-tested gloves should: 

•• 

Not be powdered, as the powder can be contaminated and then 

fall off the gloves during removal and contribute to 

contamination 

•• 

Be compatible with cleaning and decontaminating agents used in 

the workplace 

•• 

Be latex free (acceptable alternatives include neoprene, nitrile, 

and polyurethane) 

•• 

Be able to maintain their resistance to permeation by hazardous 

drugs when disinfected with alcohol 

When following best practices for the use of gloves during handling 

of hazardous drugs, workers should: 

•• 

Wear double gloves when the risk for dermal contamination with 

hazardous drugs is high (this is determined as part of your 

workplace risk assessment) 


•• 

Follow steps to avoid contamination when putting on gloves and 

during removal, including washing hands before and after 

wearing gloves 

•• 

Change gloves after 30 minutes of continuous compounding or if 

they have been contaminated or compromised 

•• 

Remove outer gloves before taking them out of a biological 

safety cabinet 

Chemotherapy-tested gowns 

Chemotherapy-tested gowns used for handling hazardous drugs 

must be worn when there is risk of bodily contact with hazardous 

drugs or contaminated patient body fluids and waste during the 

precautionary period. 

Gowns should: 

•• 

Be identified by the manufacturer as gowns for handling 


•• 

Be moisture resistant with long sleeves and tight-fitting cuffs 

•• 

Have a closed front that covers the worker from shoulders to 

knees and fastens in the back 

•• 

Be disposable 

When following best practice for the use of chemotherapy gowns 

with hazardous drugs, workers should: 

•• 

Change the gown every 3.5 hours or immediately when 

contaminated or compromised 

•• 

Wash hands immediately after removing a gown 

Chemotherapy gowns should meet the requirements of ASTM 

Standard F739-99a Standard Test Method for Resistance of 

Protective Clothing Materials to Permeation by Liquids or Gases 

under Conditions of Continuous Contact or a comparable standard. 

Respirators 

An approved and fit-tested respirator must be worn when there is a 

risk of exposure to airborne particulates, aerosols, or vapours from 

hazardous drugs. 

The respirator selected must provide protection from particulates as 

well as gases or vapours that can be generated from solid or liquid 

forms of hazardous drugs, depending on the activity. This could 

include a half-or full-face air-purifying respirator that has a 

particulate filter (such as P100) and a chemical cartridge that 

removes vapour contaminants from air as it is inhaled. 

66 


The choice of respirator must be made as part of the risk assessment 

based on the potential exposure to airborne particulates, aerosols, or 

vapours from hazardous drugs for each task in the workplace. Fit 

tests must also be carried out before a respirator is issued to a 

worker. The worker must perform a seal check before each use. 

Refer to the WorkSafeBC publication Breathe Safer: How to 

Use Respirators Safely and Start a Respirator Program for more 

information on how to select an appropriate respirator. 


Face protection, such as full or partial face shields and goggles, 

should be worn when there is a risk of splashing, which may occur 

when handling liquid forms of hazardous drugs or contaminated 

body fluids and waste. 

When following best practice for wearing face protection for 

hazardous drugs, workers should: 

•• 

Wear full face shields 

•• 

Use disposable face protection whenever practicable 

•• 

Clean non-disposable face protection immediately after use 

Footwear and shoe covers 

Workers must ensure their footwear is in a condition to provide 

protection against exposure to hazardous drugs, such as by wearing 

closed shoes that are made of a material that prevents liquids from 

soaking through. Refer to section 8.22 of the Regulation for more 

information on the requirements for footwear. 

Shoe covers are part of sterile preparation procedures but also help 

reduce exposure by preventing contamination being spread to other 

areas of the workplace on workers’ shoes. 

Best practices for footwear and shoe covers include, but are not 

limited to: 

•• 

Having a dedicated set of footwear that is only used in the 

preparation area 

•• 

Having all workers wear shoe covers when entering a sterile 

preparation room 

•• 

Removing shoe covers with gloved hands and disposing as 

hazardous waste upon exiting the preparation room 

•• 

Wearing shoe covers when cleaning up spills or broken 

containers on the floor 


Appendix 5: 

Biological safety cabinets (BSCs) 





place at the facility, an 

approved BSC must 

be provided and used. 







device where 




Regulation. 


Type A1 and A2 

cabinets must not 

be used for the 

preparation of 

cytotoxic drugs. A 

minimum Class II Type 

B must be used when 

preparing cytotoxic 

drugs. See section 


A biological safety cabinet (BSC) should be used for all preparation 

activities with hazardous drugs. The information in this appendix 

outlines which BSCs are appropriate for use with hazardous drugs. 

For more information on BSCs, refer to the Canadian Biosafety 

Standards and Guidelines, First Edition. 

Class I BSCs 

A Class I BSC provides environmental and personnel protection, 

but does not provide sterile conditions for the product. The 

Regulation states that a Class I BSC is not acceptable for use with 

cytotoxic drugs, however it may be permitted if it is designed to be 

total exhaust. Depending on whether non-sterile activities are 

carried out in the workplace, the use of Class I BSCs with 

hazardous drugs may need to be evaluated with a WorkSafeBC 

occupational hygiene officer. 

Class II BSCs 

Class II Type A BSCs recirculate HEPA-filtered air back into the 

preparation room and, because of this, do not meet the ventilation 

requirements under the Regulation. Since HEPA filters only protect 

against particulate contamination and not gases or vapours, this 

recirculated air must be considered a potential risk for workers in 

the preparation room to be exposed to hazardous drugs. For this 

reason, Class II Type A1 and Type A2 BSCs should not be used for 

the preparation of hazardous drugs. 

Class II Type B BSCs do not recirculate HEPA-filtered air into the 

preparation room and should be used for ventilation and 

containment control for preparations of hazardous drugs. However, 

it is best practice to use a Class II Type B2 BSC, since they 

externally exhaust all air that passes through the cabinet. 

Class III BSCs and isolators 

Class III BSCs and isolators could potentially provide additional 

protection against exposure because they are completely enclosed 

and air tight. Unlike other classes of BSCs, they have a glass barrier 

between the worker and the preparation. When being used for 

68 


containment, they are kept at negative air pressure to the 

surrounding room. Preparations enter and exit the BSC via passthrough 

hatches with interlocking doors, and workers reach 

preparations inside the cabinet by placing their hands inside builtin 

glove assembly fixtures. 

Class III BSCs and isolators are not typically used for hazardous drug 

preparation. Any Class III BSC or isolator used for hazardous drug 

preparations must meet the operational requirements for BSCs as 

described in the Regulation. Refer to section 30.12 of the Regulation. 

Class 

of BSC 

Recirculated 

air 

Permitted for Cytotoxic 

Drugs under the Regulation 

Recommended Best Practice 

for Hazardous Drugs 

Class I 

Can be total 

exhaust or 

partial exhaust 

No 

No 

Class II 

Type A 

70% into BSC, 

30% into 

preparation 

room 

No 

No 

Class II 

Type B1 

30% into 

the BSC 

Yes 

No 

Class 

II Type 

B2 

0% Yes Yes 

Class III 0% Yes No 

A comparison of the BSC classes and their uses according to the Regulation and recommended by 

best practice. 


Appendix 6: 

Selection of medical equipment 

Not all equipment is suitable for use with hazardous drugs. 

Where applicable, equipment that is selected for use with 

hazardous drugs should: 

•• 

Be approved for use with hazardous drugs by the manufacturer 

•• 

Eliminate or minimize the release of hazardous drugs in the form 

of liquids, solids, or vapours as much as reasonably possible 

•• 

Clearly indicate any functions where the equipment is not a 

closed system, if it is marketed as a closed-system transfer 

device 

•• 

Be supported by evidence that demonstrates the effectiveness of 

the equipment at reducing environmental contamination in 

occupational settings 

Employers should periodically review the equipment and supplies 

used for hazardous drugs for their effectiveness at reducing 

exposure. 

70 


Appendix 7: Cleaning agents 

Effective cleaning and decontamination is a key part of reducing 

hazardous drug surface contamination. Hazardous drug 

contamination has been detected on surfaces even after cleaning 

using conventional methods and cleaning products. Hazardous 

drug contamination may accumulate in porous materials. 

No single cleaning agent can be used in all situations. The 

effectiveness of a cleaning or decontaminating agent depends on 

the chemical and physical properties of the drug, as well as the 

surface that is being cleaned. 

Workplaces should have multiple cleaning and decontaminating 

supplies that are effective on different drugs, or at least different 

types of drugs based on their chemical and physical properties. 

When selecting cleaning and decontamination supplies, 

workplaces should consider: 

•• 

Current research on the effectiveness of different procedures 

and agents on the types of hazardous drugs being used in the 

workplace 

•• 

Surfaces (e.g., stainless steel BSC) that may have specific 

cleaning requirements outlined by the manufacturer 

•• 

The characteristics of the surfaces that will be cleaned and 

decontaminated, such as porosity and texture 

•• 

The ease of use, such as having pre-packaged wipes soaked in 

solution 

•• 

The potential for hazardous by-products from cleaning and 

decontamination products, or products that are hazardous 

themselves 


The table below compares some of the cleaning and decontaminating agents commonly used 

on surfaces that may have hazardous drug contamination. 

Deactivating 

agent 

Decontaminating 

agent 

Disinfecting 

agent 

Cleaning 

agent 

Mode of 

action 

Breaks down 


Physically removes 


Surface 

disinfection 

Removes 

organic and 

inorganic 

material 

Examples 

Hypochlorite 

(household bleach) 

Laboratory-grade 

detergents 

Ethyl alcohol, 

70% isopropyl 

alcohol 

Chlorhexidine 

Benefits 

•• 

Highly effective at 

deactivating 

several commonly 

used hazardous 

drugs 

•• 

Relatively safer 

than bleach 

•• 

Convenience 

•• 

Use of different 

solvents can 

improve 

efficiency against 

different drugs 

•• 

Commonly 

used in 

routine 

disinfection 

procedures 

•• 

Commonly 

used in 

routine 

cleaning 

procedures 

Challenges 

•• 

Can produce 

hazardous byproducts 

•• 

Known to corrode 

stainless steel (this 

can be minimized 

by following with a 

neutralizing agent) 

•• 

Can cause skin, 

eye, and respiratory 

irritation 

•• 

May be 

less effective 

when 

contamination 

is unknown 

•• 

Higher 

concentrations 

may leave 

residues that can 

trap hazardous 

drugs 

•• 

Do not directly act on 


•• 

Can leave residues that trap 

microbes or hazardous drugs 

and spread them around 

•• 

Should not be used as the sole 

agent for removing hazardous 

drug contamination 

72 


Appendix 8: Spill kit checklist 


Spill kits must be 

present where 


used in the workplace. 



Spill kits should be available wherever hazardous drugs are 

handled. Best practices for the contents of a spill kit include: 

Laminated, written instructions 

 

Warning signs and plastic “caution” tape to alert other staff to 

the hazard and to isolate the spill area 

Personal protective equipment (PPE): 

Chemotherapy-tested gown 

Two pairs of chemotherapy-tested gloves 

Disposable eye goggles or face shield 

Shoe covers 

N95 or better respirator mask 

Disposable scoop and scraper 

 

 

An absorbent spill pad for small volumes of liquid 

A spill pillow capable of absorbing very large volumes of liquid 

(if not practical to fit inside the spill kit, this may be located 

separately and retrieved when required) 

Two large plastic waste disposal bags 

Concentrated alkaline detergent solution 

 

 

 

Bottled water, of the correct volume for diluting the detergent 

Clearly labelled hazardous waste container 

Information on reporting the spill and potential worker exposure 


WorkSafeBC offices 

Visit our website at worksafebc.com. 

Abbotsford 

2774 Trethewey Street V2T 3R1 

Phone 604.276.3100 

1.800.292.2219 

Fax 604.556.2077 

Burnaby 

450 – 6450 Roberts Street V5G 4E1 

Phone 604.276.3100 

1.888.621.7233 

Fax 604.232.5950 

Coquitlam 

104 – 3020 Lincoln Avenue V3B 6B4 

Phone 604.276.3100 

1.888.967.5377 

Fax 604.232.1946 

Courtenay 

801 30th Street V9N 8G6 

Phone 250.334.8765 

1.800.663.7921 

Fax 250.334.8757 

Kamloops 

321 Battle Street V2C 6P1 

Phone 250.371.6003 

1.800.663.3935 

Fax 250.371.6031 

Kelowna 

110 – 2045 Enterprise Way V1Y 9T5 

Phone 250.717.4313 

1.888.922.4466 

Fax 250.717.4380 

Nanaimo 

4980 Wills Road V9T 6C6 

Phone 250.751.8040 

1.800.663.7382 

Fax 250.751.8046 

Nelson 

524 Kootenay Street V1L 6B4 

Phone 250.352.2824 

1.800.663.4962 

Fax 250.352.1816 

North Vancouver 

400 – 224 Esplanade Ave. W. V7M 

1A4 

Phone 604.276.3100 

1.888.875.6999 

Fax 604.232.1558 

Prince George 

1066 Vancouver Street V2L 5M4 

Phone 250.561.3700 

1.800.663.6623 

Fax 250.561.3710 

Surrey 

100 – 5500 152 Street V3S 5J9 

Phone 604.276.3100 

1.888.621.7233 

Fax 604.232.7077 

Terrace 

4450 Lakelse Avenue V8G 1P2 

Phone 250.615.6605 

1.800.663.3871 

Fax 250.615.6633 

Victoria 

4514 Chatterton Way V8X 5H2 

Phone 250.881.3418 

1.800.663.7593 

Fax 250.881.3482 

Head Office / Richmond 

Prevention Information Line: 

Phone 604.276.3100 

1.888.621.7233 (621.SAFE) 

Administration: 

6951 Westminster Highway 

Phone 604.273.2266 

Mailing Address: 

PO Box 5350 Stn Terminal 

Vancouver BC V6B 5L5 

After hours 

health & safety emergency 

604.273.7711 

1.866.922.4357 (WCB.HELP) 

R13/09

11/15 Printed in Canada 

BK153

Safe Handling of Hazardous Drugs

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