SAFE HANDLING OF HAZARDOUS MEDICATIONS (CYTOTOXIC AND NON-CYTOTOXIC) POLICY POLICY # 110.160.010 NEWLY REVISED: OCTOBER 2015 AVAILABLE AT: HTTP://HOME.WRHA.MB.CA/PROG/MEDQUALITY/POLICIES.PHP
Safe Handling of Hazardous Medication First approved in October 2007 as the Safe Handling of Cytotoxic Medications Policy and focused mainly on the handling of IV chemotherapy. In July 2012 a revision of the policy included ALL hazardous medications, both cytotoxic and non-cytotoxic, and information about handling ALL dosage forms of these medications.
This current revision (2015) reflects current national and international safe handling guidelines. It also addresses the special considerations around handling cytotoxic medications in the long term care and community home care sectors. There are some changes that affect ALL staff.
Learning Objectives: To outline the new procedures in this policy. To review some of the key procedures that still exist.
What s New: Policy is now Level 1 It is applicable to all WRHA governed sites and facilities. Chemo gloves AND chemo gown are required when administering parenteral cytotoxic medications. Face/eye protection & shoe covers are recommended whenever there is potential for splashing. (See Appendix A, pg. 10)
What Else is New: IV infusion bags containing cytotoxic medications cannot be spiked at the patient bedside to prevent inadvertent contamination of the area. (pg. 6, #4.10) Statement added about labelling of diagnostic specimens and requisitions to alert respiratory and laboratory staff acquiring samples and performing tests on the samples. (pg. 5, #3.12) Recommendation that outpatient prescriptions are clearly noted as cytotoxic medications when written. (pg. 4, #3.10)
And Safe Handling of Medications Chart (Appendix A) modified. First page addresses hazardous medication administration and subsequent patient care. Second page mainly addresses hazardous medication preparation. To download or copy chart only see: http://home.wrha.mb.ca/prog/medquality/policies.php
Clarified Information About: Partial doses of parenteral cytotoxic medications; will be discarded on the patient care area, not returned to pharmacy, regardless of remaining volume. (pg. 7, #4.14) Transport of patients while cytotoxic medications infusing. (pg. 7, #4.13) Handling of cytotoxic medication waste and human waste and added information specific to Personal Care Homes and Home Care. (pg. 5, #3.13 and 3.14; pg. 7. # 4.16 & 4.20)
Clarified Information About: Handling of laundry; must be in waterproof laundry bag or plastic bag but no additional special handling required Routine practices always recommended. (pg. 7, #4.17) Cleaning of non-disposable items. (pg. 7, #4.19) Addressing staff concerns when handling hazardous medications while pregnant, attempting to become pregnant or breast feeding. (pg. 5, #3.11)
Clarified Information About: Cytotoxic Spill Management (Appendix B). Size of spill requiring Cytotoxic Spill Kit has been increased to 100 ml. Information about managing spills of tablets or capsules included. To download or copy chart only see: http://home.wrha.mb.ca/prog/medquality/policies.php
Worth Repeating: Cover toilets/hoppers with a plastic lined pad before flushing and should be flushed twice. (pg. 7, #4.18) All disposable items in contact with blood/body fluids during cytotoxic precautions must be discarded in the cytotoxic waste container (e.g. graduates, dressings, needles used for injections). (pg. 5, #3.14) Spills of blood/body fluids of a patient on cytotoxic precautions should be treated as a cytotoxic spill.
Questions can be directed to the appropriate Policy Contact: Nina Kostiuk, Director of Nursing, CCMB Ruth Loewen, Director, CCMB Community Oncology Program & WRHA Oncology Program Kathy Ramesar, Adult Oncology Nurse Clinician, HSC Dr. David Szwajcer, Adult Clinical BMT Director Barbara Sproll, WRHA Medication Safety Pharmacist