Safe Handling of Chemotherapy Agents
Both oral and intravenous chemotherapy agents, and other drugs used to treat patients with cancer, can be hazardous to medical personnel who prepare, dispense, and administer these drugs, as well as to patients and their families. The Oncology Pharmacist spoke about safe-handling procedures and guidelines with Anne Marie Oberle, PharmD, BCOP, Advance Practice Clinical Oncology Pharmacist at the Kimmel Cancer Center at Thomas Jefferson University Hospital in Philadelphia, Pennsylvania.
Are there guidelines in place for safe handling of hazardous substances in the workplace?
Anne Marie Oberle (AMO): NIOSH [National Institute for Occupational Safety and Health], OSHA [Occupational Safety and Health Administration], and ASHP [American Society of Health-System Pharmacists] have developed guidelines for safe handling in the workplace. The ASHP guidelines were developed in 2007 and are mainly consistent with NIOSH regarding employee protection. I usually follow NIOSH guidelines, since they are the most recent.
Which drugs used to treat cancer patients pose hazards to pharmacists and other staff who handle these drugs?
AMO: Many medications for cancer patients can cause acute and even long-term harm. This includes both oral and intravenous (IV) drugs. Most people don’t realize that oral drugs can be hazardous, and that crushing and dissolving them can also expose people and the environment. Employees must handle oral and IV drugs appropriately with the same precautions. Our Pharmacy Department has policies in place regarding handling, for both oral and IV formulations, to protect all staff, including nurses.
Can you give specific examples of hazardous drugs?
AMO: Older chemotherapy agents such as doxorubicin and ifosfamide; oral and IV formulations of methotrexate, cyclophosphamide, and tyrosine kinase inhibitors; and drugs used to treat other conditions outside of cancer, such as ganciclovir, ribavirin, and porfimer.
What are examples of some of the safe-handling policies?
AMO: Appropriate handling involves containing the substance with overwrap and clear labeling. When we dispense chemotherapy, we decontaminate the product with bleach prior to labeling, and prime the IV tubing with primary solution first and then adding chemotherapy to the bag. This is done to limit the risk to the nursing staff. Staff must wear personal protective equipment when unpacking medications from the manufacturer.
The vials themselves can be contaminated on the surface when they come from the manufacturer. According to an older article from ASHP, just putting medications on the shelf can expose you. The staff protect themselves the same way when compounding chemotherapy.
What about training oncology pharmacists for safe handling?
AMO: All our staff—technicians and pharmacists—go through rigorous training and education about gowning, double-gloving, wearing masks, and how to protect themselves from exposure.
How do you keep the staff up to date on safe-handling procedures?
AMO: We perform an annual review (and more often if necessary) and give the staff updated competency exams that they are required to complete. After the initial training, we observe them and question them daily to make sure they are following our procedures. If they are not, we let them know that they are creating risks for the entire staff and that they need to follow our policies and guidelines.
There hasn’t been much change in safe-handling practice guidelines over the past 5 years or so. NIOSH publishes a list of hazardous medications and we update our policies based on that.
What do you tell patients about safety issues?
AMO: It is my impression that there is a deficit in patients’ understanding that oral medications may be contaminated and can pose risks to their family, including children and grandchildren. Patients can excrete toxins through their tears, sneezing, urine, and other body fluids. It is preferable that they use their own bathroom at home when on treatment, but if they share a bathroom, they should flush the toilet twice, and need to wear gloves when cleaning, as well as using bleach to wipe down the bathroom. Also they are told not to flush oral medications down the toilet.
If medications need to be crushed, they are taught the safest way to do this. Medications should never be smashed on the countertop, for example.
The main principle is containment. Never use the same eating and drinking utensils that the patient has used until it has been sterilized in the dishwasher. In the hospital, when a patient can’t swallow and we need to prepare a suspension, the tablet is crushed in a closed environment and handed back to the nurses in the safest way.
The American Cancer Society has good education materials for patients and families about how to handle chemotherapy safely.
How do you promote a culture of safety?
AMO: I have deep concerns about this. Education is key. The person in charge must be vigilant. A body of literature shows how to establish a culture of safety. NIOSH publishes a list of components of evaluation for those handling hazardous drugs.
How do you think safe-handling procedures can be improved in cancer centers?
AMO: We need more strict and definitive guidelines to drive change. The ASHP 2007 guidelines made my job easier because they provided more specifics.
We need to be on top of our game. Even though safe-handling procedures incur higher costs, this is a very important area of concern.