Hazardous drugs (HDs) are chemicals that demonstrate one or more of the following characteristics: carcinogenicity, genotoxicity, teratogenicity, reproductive toxicity, or organ toxicity. In addition, newer drugs with a structural or toxicity profile that mimics an agent known to be hazardous by one of the aforementioned criteria also should be treated as such (National Institute for Occupational Safety and Health [NIOSH], 2014). Healthcare workers (HCWs) potentially are exposed to HDs in the workplace during drug preparation, administration, and disposal, and when handling patients’ excreta following treatment with these drugs. More than 100 studies since 1994 have documented evidence of contamination of the work environment with HDs, which increases the potential for exposure of nurses, pharmacists, and other HCWs when these agents are handled without appropriate precautions.
More than 50 studies have demonstrated the presence of HDs in the urine of HCWs, indicating actual exposure. Occupational exposure to HDs has been associated with acute symptoms such as nasal sores and hair loss, adverse reproductive outcomes such as infertility and miscarriages, genetic changes such as DNA damage, and an increased occurrence of cancer (Centers for Disease Control and Prevention, 2014).
The Occupational Safety and Health Administration ([OSHA], 1986) acknowledged the occupational risks of HDs and issued recommendations for their safe handling nearly 30 years ago. Updated guidelines from NIOSH and professional societies subsequently have been published (American Society of Health-System Pharmacists, 2006; NIOSH, 2014; Polovich, Olsen, & LeFebvre, 2014). All guidelines address the need for HD-related policies and procedures, education and training, and safe-handling precautions in organizations in which HDs are present. Safe-handling precautions include the use of safety equipment, safe work practices, and personal protective equipment (PPE). When used consistently, recommended precautions can reduce occupational HD exposure (NIOSH, 2004).
Occupational HD exposure can be minimized by a comprehensive HD safe-handling program based on a hierarchy of controls (Connor & McDiarmid, 2006). When a hazard cannot be eliminated, engineering controls are recommended to control exposure. Biologic safety cabinets and compounding aseptic containment isolators are primary engineering controls, and closed-system transfer devices are supplemental engineering controls, both of which reduce HD exposure. Administrative controls are the next level of protection and include safe-handling policies and procedures, hazard communication, education, and medical surveillance of those who potentially are exposed. Finally, PPE that has been tested for use with HDs provides barrier protection for workers. PPE includes gowns, gloves, eye and face shields, and respirator protection, depending on the HD-handling activities.
Nurses and pharmacists usually work as employees rather than independent practitioners in hospitals, clinics, and offices; therefore, employers and employees share the responsibility for HD safe handling.
Approved by the Oncology Nursing Society Board of Directors, January 2015. Reviewed January 2016. Review by the Hematology/Oncology Pharmacy Association and the American Society of Clinical Oncology Boards of Directors, April 2016.
American Society of Health-System Pharmacists. (2006). ASHP guidelines on handling hazardous drugs. American Journal of Health-System Pharmacists, 63, 1172–1193. doi:10.2146/ajhp050529
Centers for Disease Control and Prevention. (2014). Occupational exposure to antineoplastic agents: Recent publications, guidelines, review articles and surveys. Retrieved from http://www.cdc.gov/niosh/topics/antineoplastic/pubs.html
Connor, T.H., & McDiarmid, M.A. (2006). Preventing occupational exposures to antineoplastic drugs in health care settings. CA: A Cancer Journal for Clinicians, 56, 354–365. doi: 10.3322/canjclin.56.6.354
National Institute for Occupational Safety and Health. (2004). Preventing occupational exposure to antineoplastic and other hazardous drugs in health care settings (DHHS [NIOSH] Publication No. 2004-165). Retrieved from http://www.cdc.gov/niosh/docs/2004-165/
National Institute for Occupational Safety and Health. (2014). NIOSH list of antineoplastic and other hazardous drugs in healthcare settings 2014. Retrieved from http://www.cdc.gov/niosh/docs/2014-138/pdfs/2014-138_v3.pdf
Occupational Safety and Health Administration. (1986). Guidelines for cytotoxic (antineoplastic) drugs. Retrieved from https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=DIRECTIVES&p_id=1702
Polovich, M., Olsen, M., & LeFebvre, K.B. (Eds.). (2014). Chemotherapy and biotherapy guidelines and recommendations for practice (4th ed.). Pittsburgh, PA: Oncology Nursing Society.