Safe handling of cytotoxic drugs

Cytotoxic drugs are prescribed to treat cancers and other medical conditions. There are no exposure limits set for cytotoxic drugs, however even low levels of exposure should be avoided as much as possible and with necessary safety precautions taken. Healthcare, veterinary and laboratory workers can be exposed or contaminated by cytotoxic drugs through skin or eye contact, skin absorption, inhalation of aerosols and drug particles, ingestion and needlestick injuries. Exposure can be through drug preparation or administration, handling patient waste, transport and waste disposal, and spills. Where control measures are not adequate, adverse health effects may result from exposure (eg abnormal formation of cells, alterations to normal blood cell count, foetal loss in pregnant women, abdominal pain, hair loss, nasal sores and vomitting, liver damage, contact dermatitis, local toxic or allergic reaction). What is the solution to the problem? The risks of adverse health effects from handling cytotoxic drugs can be eliminated or reduced by:

outsourcing cytotoxic drug preparation work to a company that specialises in this field purchasing cytotoxic drugs in ready-to-use concentrates to eliminate pharmacy preparation purchasing the drug in liquid rather than powder form, and in vials not ampoules ensuring the IV (pump) delivery system has an automatic backfill function establishing cleaning procedures for managing the contamination of surfaces (eg IV bags and work/floor surfaces) using strong alkaline detergent with pH>10 using a cytotoxic drug preparation area to restrict access to unauthorised persons ensuring appropriate ventilation and air-filtering systems installed in drug preparation areas using non-bevelled/wide-bore needles to transfer liquids from containers ensuring universal purple coloured cytotoxic equipment is used using labelled mops, buckets, trolleys and waste containers specifically for cytotoxic drug use using proper hand washing technique identifying cytotoxic drugs used and stored at the workplace

obtaining relevant material safety data sheets (MSDS) and educating workers about this information establishing protocols and safe work procedures for handling and using cytotoxic drugs and the disposal of related waste, in consultation with employees displaying universal cytotoxic drug signage when treatment in progress informing operating theatre and X-ray staff of patient undergoing therapy establishing and maintaining a cytotoxic drugs register evaluating the nature and risks of the work involving cytotoxic drugs establishing procedures for managing cytotoxic waste (eg identifying, containing and segregating waste, transport of waste on and off site, ensuring secure waste storage and waste treatment and disposal) providing mandatory induction and training to workers about the hazards, safe handling/use of these drugs or any new drugs introduced and correct use of personal protective equipment (PPE) following drug manufacturers' instructions for safe handling/use providing health monitoring to workers handling cytotoxic drugs, by a medical practitioner, that meets current recommendations, and providing medical advice and counselling as required ensuring cleaners, carers, patients and visitors are aware of precautions to avoid contamination from the clean-up of body waste (eg vomitus), spills and soiled linen or clothing wearing personal protective equipment such as overalls, gowns, head covering, closed footwear, gloves, safety glasses/face shields and respiratory protective devices reviewing the condition of PPE and spill kit contents regularly ensuring equipment used for administering cytotoxic drugs is purpose designed, safe to use and maintained

Procedures for managing workers exposed to cytotoxic drugs or patient body waste should include first aid, counselling, health monitoring and reporting any incidents. Work practices and risk controls should be reviewed and monitored on a regular basis. While risk assesement is not mandatory, it is a useful step for controlling risks and establishing protocols for workers handling and using cytotoxic drugs.

Spills and Contamination

Strategy for the Management of Spills and Contamination In addition to adopting and following safe work practices which aim to prevent accidental spills of cytotoxic drugs, a written strategy must be developed and maintained for the management of the spills that may occur when preventative strategies fail. Spills and breakages must be cleaned up immediately by a properly protected person trained in the appropriate procedures. All personnel likely to be involved in a cytotoxic spill should be trained in: The correct procedures for handling cytotoxic drugs or waste in order to prevent and minimise the risk of spills; The location of the spill kit in their area (see Appendix 3 for contents); The arrangements for the medical treatment of any affected personnel; The procedure for the containment of the spill and decontamination of personnel and the environment; The procedure for waste disposal according to the nature and extent of the spill; and The procedure for the safe handling of packages of cytotoxic drugs which may be damaged or leaking. A spill should be identified with a warning sign so that other persons in the area will not be contaminated.

Incident Report Forms

The circumstances and handling of all spillages should be documented on an incident report form. One copy should be kept on the departmental file for the staff member(s) involved. Another copy of this form should be sent to the person responsible for the occupational health of staff working within the hospital. Information recorded on this report form should include: Date and time of the incident; Location of the incident; Name of the drug involved; Form of the drug; Approximate concentration and quantity spilled; Names of personnel involved, including any person in the area who might have been exposed; A description of any direct skin or eye contamination; Absorption may have occurred; and A description of what action was taken

Emergency Proceduresd
Small spills that occur on-site and during transportation should be managed by the healthcare establishment. Procedures should specify under what conditions emergency services should become involved. Consideration should be given to the establishment of an emergency spill management team which includes pharmacy and cleaning personnel. All personnel likely to be involved in the handling of cytotoxic drugs and waste should have training in spill management.