Healthcare Workers Handling Hazardous Drugs Should Be Monitored in Surveillance Program

Unlike radiation exposure, exposure to hazardous drugs cannot be measured with a badge or device. Instead, healthcare workers must strive to minimize exposure to these drugs. In addition to engineering controls, safer work practices, and the use of personal protective equipment (PPE), healthcare workers should be routinely monitored in a medical surveillance program. ONS, the Occupational Safety and Health Administration (OSHA), and the American Society of Health-System Pharmacists (ASHP) all have recommendations related to employee medical surveillance.

ONS’s Safe Handling of Hazardous Drugs (Polovich, 2011) guidelines outline the recommended components of a medical surveillance program including a thorough medical, reproductive, and work history, physical examination, and laboratory studies including the following: complete blood count, reticulocyte count, aspartate transaminase, alanine aminotransferase, alkaline phosphatase, and urine microscopy or dipstick for blood. The guidelines also discuss biologic monitoring if specific exposures are being monitored for.

OSHA’s recommendations can be found in the OSHA Technical Manual in section 6, chapter 2. In the section on controlling occupational exposure to hazardous drugs, the recommendations call for both preplacement and periodic examinations. For preplacement medical examinations, “laboratory assessment may include a complete blood count with differential, liver function tests, blood urea nitrogen, creatinine, and a urine dipstick” (OSHA, 2006, section VI.A.3). For periodic examinations, OSHA states that occupational medicine experts in the hazardous drug area recommend these exams to update the employee’s medical, reproductive, and exposure histories yearly or every two to three years. The interval between examinations depends on “the opportunity for exposure, duration of exposure, and possibly the age of the worker at the discretion of the occupational medicine physician, guided by the worker’s history” (OSHA, 2006, section VI.B). The individual’s routine exposure and any acute accidental exposures are carefully documented. The physical examination and laboratory assessment are the same as for the preplacement examinations.

The ASHP Guidelines on Handling Hazardous Drugs include information regarding medical surveillance. These guidelines state: “A comprehensive safety program for controlling workplace exposure to hazardous drugs must include engineering controls, training, work practices, and PPE. Such safety programs must be able to identify potentially exposed workers and those who might be at higher risk of adverse health effects due to this exposure. . . . All workers who handle hazardous drugs should be routinely monitored in a medical surveillance program” (ASHP, 2006, p. 1185). Medical surveillance involves the collection and interpretation of data to detect health changes in working populations. Medical surveillance programs involve assessment and documentation of symptom complaints, physical findings, and laboratory values (e.g., blood counts) to identify any deviation from the expected norms. The literature contains descriptions of medical surveillance programs for hazardous drug handlers. The National Institute for Occupational Safety and Health (NIOSH) encourages employees who work with hazardous drugs to participate in workplace medical surveillance programs. However, limited resources may preclude the implementation of a comprehensive medical surveillance program for healthcare workers who are exposed to hazardous drugs. If an institutional medical surveillance program is not available, NIOSH encourages workers to inform their personal healthcare providers of their occupation and possible hazardous drug exposure when obtaining routine medical care (ASHP, 2006).


American Society of Health-System Pharmacists. (2006). ASHP guidelines on handling hazardous drugs. American Journal of Health-System Pharmacy, 63, 1172–1193. doi: 10.2146/ajhp050529

Occupational Safety and Health Administration. (1995, September 22). Section VI, chapter 2: Controlling occupational exposure to hazardous drugs [OSHA technical manual]. Retrieved from

Polovich, M. (Ed.). (2011). Safe handling of hazardous drugs (2nd ed.). Pittsburgh, PA: Oncology Nursing Society.