Safe Handling Of Hazardous Medications - WRHA PP

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SAFE HANDLING OF HAZARDOUSMEDICATIONSCytotoxic and Non-CytotoxicWinnipeg Regional Health AuthorityPolicy # 110.160.010

By the end of this presentationstaff should be able to1. Understand what information is in the newSafe Handling of Hazardous Medications Policy.2. Define what a Hazardous Medication is andwhat some of the risks of occupationalexposure are.

By the end of this presentationstaff should be able to3. Use the definitions and the charts in thepolicy to determine: the classification of the Hazardous Medication the dosage form of the Hazardous Medication how that impacts the handling precautionsrequired to minimize occupational exposure.4. Identify the steps to be taken when exposedto Hazardous Medication or when aCytotoxic Spill occurs.

Safe Handling of HazardousMedications Policy To provide direction and describe safetymeasures for the receipt, storage,preparation, transport, administration,spill clean up and waste management ofHazardous Medications.

Who Does This SafeHandling Policy Apply To? ALL employees providing direct care topatients receiving Hazardous Medications(nursing assistants, nurses, physicians,physiotherapy, etc.). ALL employees handling or transportingmedication, waste or soiled equipment (e.g.housekeeping, laundry, transport, pharmacy,shipping and receiving, etc.).

Safe Handling of HazardousMedications Policy Will Assist Staff To1. Define cytotoxic and non-cytotoxic hazardousmedications.2. Recognize & prevent potential risks and conditionsfor exposure to potentially hazardous medications.3. Determine appropriate precautions for safehandling of potentially cytotoxic and non-cytotoxichazardous medications and associated waste.4. Classify and manage a cytotoxic spill.

Safe Handling ofHazardous Medications Policy A copy of the complete Safe Handling ofHazardous Medications Policy can befound on the Medication Quality andSafety Committee page on WRHA policies.php

What Are Hazardous Medications? Medications that are known or suspected tocause adverse health effects from exposuresin the workplace. They include: antineoplastic and chemotherapy medicationsused for cancer and other diseases medications to treat auto immune diseases likearthritis antiviral medications, hormones, somebioengineered medication & other miscellaneousmedications.

What Are the PotentialRisks to Health Care Workers?Working with or near hazardous medications inhealth care settings can potentially cause: Skin rashes Infertility Miscarriage Birth defects Organ toxicities Leukemia or other cancers

How Do Staff Come in ContactWith Hazardous Medications?Direct contactPrimary physical contactwith a hazardousmedication duringpreparation oradministration or whenmanaging a hazardousmedication spill.Indirect ContactSecondary contactwith a hazardousmedication from bodyfluids, bed linens,medical equipment,etc.

Direct or Indirect?1. Touching measurable concentrations ofmedications present on drug vial exteriors,work surfaces, floors, and final medicationproducts?2. Changing the diaper of a baby receivingcytotoxic medication for leukemia?

What Can You Do to Protect Yourself?

C.H.O.I.C.EC.H.O.I.C.E is an easy toremember acronym to help staffremember the necessary stepsneeded to minimize exposure tohazardous medications.

C.H.O.I.C.EC Is the medication Cytotoxic?H Is the medication non-cytotoxicHazardous?O Is it a solid Oral intact dosage form?I Is it an Injectable or Instillationdosage form?C Is it a Compromised dosage form?E What Effect will this informationhave?

“C” Is the medication that I’m handlingCytotoxic?

“H” Is the medication non-cytotoxicHazardous?WEAR GLOVESWEAR GLOVESDO NOT CRUSH

Cytotoxic &Non-cytotoxic HazardousCytotoxicNon-Cytotoxic Medications that are Medications (other thanpotentially detrimentalcytotoxic hazardousor destructive to cellsmedications) which arewithin the body.deemed to pose apotential risk in the event Deemed to pose maximalof occupational exposurerisk in the event ofand require specialoccupational exposure.handling precautions

Cytotoxic &Non-cytotoxic Hazardous

Cytotoxic &Non-cytotoxic Hazardous A copy of the complete Cytotoxic and Non-cytotoxic Hazardous Medications Chart canbe found in the policy and as a separatecopy on the Medication Quality and SafetyCommittee page on WRHA INSITE es.php

Cytotoxic &Non-cytotoxic Hazardous azaTHIOprine Melphalan cycloSPORINE Finasteride Misoprostol VinCRIStine Ganciclovir Colchicine

“O” Is it a solid Oral intact dosage form?)dWenheopleo snTaU ule(t psblca CaettsIn

“O” If a solid Oral intact dosage form is notappropriate for administration to yourpatient (can not swallow tablet,medication is administered through afeeding tube, etc.) – DO NOT CRUSHTABLET or OPEN CAPSULE Contact pharmacy for assistance.

“I” Is it an Injectable dosage form or adosage form that will be Instilled into abody cavity?IV, IM, subcut, IT, bladder instillation etc.

“C” Is it a Compromised dosage form?

“C” Pharmacy will purchase or prepare a liquiddosage form if required for your patient. If this is not available, they may suggest theDissolve-and-Dose or Crush-Dissolve-and-Dosemethod of medication administration. Contact pharmacy for full instructions onusing this method and to ensure that themedication can be administered in thismanner.

“E” What Effect will this information have?

Safe Handling of Medications Chart A copy of the complete Safe Handling ofMedications Chart can be found in thepolicy and as a separate copy on theMedication Quality and Safety Committeepage on WRHA INSITE es.php

Summary of Key Points WhenHandling Hazardous Medications Hazardous medications can potentially causeharm to workers. Hazardous medications can be classified ascytotoxic and non-cytotoxic. C.H.O.I.C.E is an acronym to be used with thesafe handling of medications chart todetermine proper handling procedures.

Other Points About Safe Handlingof Hazardous Medications Be familiar with the policy. Change gloves every 30 minutes. Report any exposure (direct and indirect contact /skin puncture) with hazardous medication toimmediate supervisor. Discuss concerns about pregnancy, breast-feedingor attempt to reproduce with your supervisor may lead to temporary reassignment.

When Does This SafeHandling Policy Apply ? Greatest risk activities: preparation andadministration of medication. Lesser risk activities: handling human waste ofpatients known to have received a hazardousmedication in the last 48 hours. Staff should ensure they are wearingappropriate personal protective equipment(PPE) for each of these levels of exposure.

Preparation of Non-CytotoxicHazardous Medication Prepared by pharmacy or by nurse.– Site specific guidelines apply – contact yourpharmacy for more information. Dispensed medications are labelled andpackaged to reflect hazardous nature ofmedications.WEAR GLOVESWEAR GLOVESDO NOT CRUSH

Administration of Non-cytotoxicHazardous Medication ALL routes of administration pose risk ofexposure and all doses – regardless ofdisease treated – are potentially hazardous.Don PPE (wear exam gloves)Tablets or capsules shall not be split, orcrushed in a patient care area prior toadministration. Contact Pharmacy for assistance.

Administration of Non-cytotoxicHazardous Medication Ensure central or peripheral line is patentand blood return present / adequate whenadministering IV Non-cytotoxic HazardousMedication.Post-infusion – flush with plain IV solution toensure it’s clear of Non-cytotoxic HazardousMedication before disconnecting.

Preparation of CytotoxicHazardous Medication Prepared by pharmacy. Cytotoxic Hazardous Medications (alldosage forms) labelled with CytotoxicSymbol. Packaged in sealable plastic bag (e.g.Ziploc ).– Parenteral doses are double bagged.

Preparation of CytotoxicHazardous Medication Syringes – dead end luer-lock syringe cap. Parenteral infusion bags: tubing sets attached and primed bypharmacy with solution not containing theCytotoxic Hazardous Medication (exceptpediatric preparations). sets sealed with a dead end luer-lock cap.

Items That May BeRequired When AdministeringCytotoxic Hazardous Medication Cytotoxic Spill Kit (differentthan the regular spill kit) Chemotherapy gown Procedure mask Red cytotoxic wastecontainer Chemo gloves Plastic backed absorbentpads Cytotoxic sign

Administration ofCytotoxic Hazardous Medication ALL routes of administration pose risk ofexposure and all doses – regardless of diseasetreated – are potentially hazardous. Cytotoxic Signs/Symbols posted duringadministration (if applicable) & for 48 hoursafter the last dose administered.

PPE for Administration CytotoxicHazardous Medication Required for all routes of administration Chemo Gloves – 12 inch cuffs Recommended for administration ofinjectable/instillation & compromised doses Chemo Gown – lint free, low permeabilityfabric Procedure mask

Administration of InjectableCytotoxic Hazardous Medication1. All manipulation (once removed from plasticsealable bag) to take place on plastic backedabsorbent pad (absorb side up).2. Ensure central or peripheral line is patentand blood return present / adequate whenadministering IV Cytotoxic HazardousMedication.

Administration of InjectableCytotoxic Hazardous Medication3. Post-infusion – flush with plain IV solution toensure it’s clear of Cytotoxic HazardousMedication before disconnecting.4. When disconnecting from med port – 2x2”gauze/alcohol pad used to absorb anydroplets – dispose in Cytotoxic Wastecontainer.

Administration of InjectableCytotoxic Hazardous Medication5. Transport of pt with Cytotoxic HazardousMedication infusion out of pt care area –minimized.6. If essential – Cytotoxic Spill Kit and stafftrained in Cytotoxic Spill management toaccompany pt.7. Inter-facility transport of pt – minimized. Ifessential – RN trained in Cytotoxic Spillmgmt shall accompany pt & remain at alltimes.

Administration of InjectableCytotoxic Hazardous Medication8. Cytotoxic Hazardous Med discontinued /temporarily stopped partway thru’ admin: Clamp tubing and / or apply a dead end luer-lockcap.Storage – discuss with pharmacy if necessary.9. Place all Bulk Cytotoxic Waste for pharmacydisposal in double sealable plastic bags labelledwith a Cytotoxic Symbol – Hand Deliver

Administration of Solid OralCytotoxic Hazardous Medication Don PPE (wear chemo gloves) Tablets or capsules shall not be split orcrushed in a patient care area prior toadministration. Contact Pharmacy for assistance.

Administration of CompromisedCytotoxic Hazardous Medication Don PPE (chemo gloves required, chemogown and procedure mask recommended) Discuss any administration issues withPharmacy.

Disposal of CytotoxicMedication Waste Don PPE (chemo gloves required) All items used while handling cytotoxic hazardousmedications (parenteral, oral, inhalation, etc.) areconsidered Medication and/or Human CytotoxicWaste – shall be discarded in Cytotoxic WasteContainer. Cytotoxic Waste Container to be disposed when ¾ full. Cytotoxic Waste Container sealed and labelled withCytotoxic Symbols prior to collection.

Disposal of CytotoxicHuman Waste Don PPE (chemo gloves require, chemo gownand procedure mask recommended) Safe Handling of Human Cytotoxic Wastefollowed x 48 hrs after last dose – regardlessof route of administration. Contaminated laundry items – kept separatefrom other items in waterproof laundry bagand sent to laundry service.

Disposal of CytotoxicHuman Waste Personal items / clothing – sent home forcleaning (launder separate from otherclothes). Laundry bags (plastic) with contaminatedclothes – sealed and sent to laundry services. Non-disposable items/equipment washedwith detergent solution and rinsed withcopious amounts of water – while wearingchemo gloves.

Disposal of CytotoxicHuman Waste Cover toilets before flushing. For toilets with no lids – cover bowl withdisposable plastic-backed pad prior toflushing. Disposable pad disposed in Cytotoxic WasteContainer.

Exposure to Hazardous MedicationImmediately after all Exposure to HazardousMedications or Waste. Eyes - Flush affected eye(s) with copious amountsof clean water or normal saline for a minimum of15 minutes. Skin - Remove contaminated clothingimmediately. Wash affected area with soap andrunning water for a minimum of 15 minutes.

Exposure to Hazardous Medication Skin Puncture - Wash puncture site thoroughly withsoap and running water for a minimum of 15 minutes.Squeeze puncture site to encourage bleeding.Report any Exposure to your immediate supervisor.Appropriate site-specific reporting documentationshall be completed e.g. Patient Safety Event Report(occurrence report), work related injury near missforms.

Cytotoxic SpillsUncontainedContained/Less Than 25 mL Cytotoxic Hazardous Cytotoxic HazardousMedication or HumanMedication or HumanCytotoxic Waste in anCytotoxic Waste in anunintended location notunintended location thatconfined within ais confined in such acontainer or onmanner that it cannot beabsorbent material;spread or dispersedwhich exists in suchmanner that it can bespread or dispersed

Cytotoxic Spill Management A copy of the Spill Management Algorithmcan be found in the policy and as a separatecopy on the Medication Quality and SafetyCommittee page on WRHA INSITE es.php

1. Define cytotoxic and non-cytotoxic hazardous medications. 2. Recognize & prevent potential risks and conditions for exposure to potentially hazardous medications. 3. Determine appropriate precautions for safe handling of potentially cytotoxic and non-cytotoxic hazardous medications and as

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