Policy for Handling the Spillage of Cytotoxic and Anti-Cancer Drugs Department / Service: Pharmacy Originator: Stephanie Cook Accountable Director: Nick Hubbard Approved by: Medicines safety committee Date of approval: 23 rd June 2015 Extension approved by TMC on: 22 nd July 2015 First Revision Due: 22 nd vember 2017 Target Organisation(s) Worcestershire Acute Hospitals NHS Trust Target Departments All areas that handle or administer cytotoxic drugs Target staff categories All nursing, medical and pharmacy staff who administer, transport or handle cytotoxic drugs or other anti-cancer drugs including monoclonals. Policy Overview: This guideline has been devised to give specific guidance on how to handle spillage of cytotoxic and other anti-cancer drugs including monoclonals. Details are given for spillages on hard surfaces, fabrics including clothing and skin or eyes. The guideline also lists personal protective equipment and safety equipment which is available in spillage kits, how to use this equipment and the location of these kits. Key amendments to this Document: Date Amendment By: 10/06/13 Add new kit locations, ITU at the Alex and Lavender S.Cook Gynaecology at WRH 10/06/13 New document template S.Cook 10/06/13 Change title to cover anti-cancer agents S.Cook 14/06/13 Policy approved for republication by accountable Nick Hubbard Director 23/06/15 Document extended for 3 months whilst being A Catterall reviewed 21/10/20 15 Document extended for 12 months as per TMC paper approved on 22 nd July 2015 TMC WAHT-PHA-002 Page 1 of 10 Version 2.5
Contents page: 1. Introduction 2. Scope of this document 3. Definitions 4. Responsibility and Duties 5. Policy detail 6. Implementation of key document 6.1 Plan for implementation 6.2 Dissemination 6.3 Training and awareness 7. Monitoring and compliance 8. Policy review 9. References 10. Background 10.1 Equality requirements 10.2 Financial Risk Assessment 10.3 Consultation Process 10.4 Approval Process Supporting Documents Supporting Document 1 Equality Impact Assessment Supporting Document 2 Financial Risk Assessment WAHT-PHA-002 Page 2 of 10 Version 2.5
1. Introduction This guideline has been devised to give specific guidance on how to handle spillage of cytotoxic and other anti-cancer drugs including monoclonals. Details are given for spillages on hard surfaces, fabrics including clothing and skin or eyes. The guideline also lists personal protective equipment and safety equipment which is available in spillage kits, how to use this equipment and the location of these kits. 2. Scope of this document This policy covers the handling of spillage of all cytotoxic and anti-cancer drugs on all surfaces. 3. Definitions Cytotoxic drugs- drugs that are toxic to cells 4. Responsibility and Duties All nursing staff who administer cytotoxic drugs All medical staff who administer cytotoxic drugs All pharmacy staff who handle cytotoxic drugs 5. Policy Detail LOCATION OF SPILLAGE KITS The kits are located:- Alexandra Hospital Garden Suite Ward 18 Ward 14 (ECU) ITU Pharmacy aseptic suite change room Pharmacy stores Worcester Royal hospital Laurel 3 ward level 1 Rowan suite oncology/haematology level 2 Childrens Clinic WRH CIU level 1 WRH Lavender Gynaecology Pharmacy aseptic suite Pharmacy stores Kidderminster Hospital WAHT-PHA-002 Page 3 of 10 Version 2.5
Millbrook suite Room 10 KGH (for intravesical) Aconbury West Highfield rheumatology ward Highfield rheumatology day case CONTENTS OF THE SPILLAGE KIT ITEM QUANTITY Filtered face piece respirator (FFP2 or 1 FFP3) Blue Roll (absorbent paper) 1 Absorbent pad (50x40cm) 2 Nitrile gloves (non sterile) (large) 4 Chemoprotect gown (codan) 1 Overshoes 4 Safety glasses (BS EN 166) 1 Plastic tweezers 1 Plastic aprons 2 Armlets 4 Cytotoxic waste bag (yellow and purple) 2 Sodium Bicarbonate 8.4% 250 ml 2 Bottle sterile water 1 litre 1 Cytotoxic waste container (purple lid) 1 (large) Cytotoxic spillage sign 1 Spillage policy 1 GENERAL POINTS Do not delegate cleaning of a spill to domestic staff. After using a spill kit contact the pharmacy department or pharmacist on call as soon as possible for a replacement. COSHH data sheets for all cytotoxic products are held within pharmacy departments at the Alexandra hospital and Worcester Royal hospital. NOTE there is currently no evidence to support the use of specific decontamination agents to denature cytotoxic drugs. LIQUID SPILL 1. Call for assistance and warn others 2. Cordon off the area to avoid spreading 3. DO NOT LEAVE THE SPILL UNGUARDED. 4. Obtain the cytotoxic spillage kit. 5. Put the cytotoxic spill sign in place to warn others. 6. From the kit put on:- Respirator mask Two pairs of nitrile gloves Goggles WAHT-PHA-002 Page 4 of 10 Version 2.5
Overshoes Chemoprotect gown 7. Soak up the spill using blue roll for small spills OR absorbent pad for large spills by working from the outside of the spill to the inside the spill, placing the blue roll or pad gently over the spill to avoid splashing. 8. Pick up any broken or sharp material with tweezers. 9. Place the blue roll or pad and any sharp material in the cytotoxic waste container. 10. Using blue roll, clean the spill area with detergent and water at least three times. Use a new section of blue roll for each clean and place into the cytotoxic waste container. 11. Treat all waste and personal protective equipment used as cytotoxic. 12. Place all waste into cytotoxic waste container or cytotoxic waste bag. 13. Complete printed label section details on waste bag or waste container used. 14. Use bag ties to seal waste bag. 15. Wash hands thoroughly. 16. Dispose of waste following normal cytotoxic waste procedures. 17. Complete a Datix incident report to include all standard information required Drug spilt Approximate volume Liquid/powder POWDER SPILL 1. Call for assistance and warn others 2. Cordon off the area to avoid spreading 3. DO NOT LEAVE THE SPILL UNGUARDED. 4. Obtain the cytotoxic spillage kit. 5. Put the cytotoxic spill sign in place to warn others. 6. From the kit put on:- Respirator mask Two pairs of nitrile gloves Goggles Overshoes Chemoprotect gown 7. Use water to moisten the blue roll. 8. Gently place over the powder and scoop up the powder inside the blue roll. 9. Work from the outside of the spill to the inside the spill. 10. Pick up any broken or sharp material with tweezers. 11. Place the blue roll or pad and any sharp material in the cytotoxic waste container. 12. Using blue roll, clean the spill area with detergent and water at least three times. Use a new section of blue roll for each clean and place into the cytotoxic waste container. 13. Treat all waste and personal protective equipment used as cytotoxic. 14. Place all waste into cytotoxic waste container or cytotoxic waste bag. 15. Complete printed label section details on waste bag or waste bin used. 16. Use bag ties to seal waste bag. 17. Wash hands thoroughly. 18. Dispose of waste following normal cytotoxic waste procedures. WAHT-PHA-002 Page 5 of 10 Version 2.5
19. Complete a Datix incident report to include all standard information required Drug spilt Approximate volume Liquid/powder SPILLAGE ON BED LINEN Put all contaminated bed linen into a cytotoxic waste bag. Complete printed label section details on waste bag. Use bag ties to seal waste bag. Dispose of waste following normal cytotoxic waste procedures. Complete a Datix incident report to include all standard information required Drug spilt Approximate volume Liquid/powder SPILLAGE ON CLOTHES Change immediately from contaminated clothes Put all contaminated clothes into a cytotoxic waste bag. Complete printed label section details on waste bag. Use bag ties to seal waste bag. Dispose of waste following normal cytotoxic waste procedures. (If this is not possible, the clothes must we washed several times with copious amounts of hot soapy water.) Complete a Datix incident report to include all standard information required o Drug spilt o Approximate volume o Liquid/powder SKIN CONTAMINATION 1. MITOMYCIN- Rinse the skin thoroughly with copious amounts of Sodium Bicarbonate 8.4%solution followed by copious amounts of soap and water. 2. ALL OTHER CYTOTOXIC PRODUCTS- Rinse thoroughly with copious amounts of water and then soap and water for 15minutes. 3. Seek medical advice if irritation occurs. 4. Complete a Datix incident report to include all standard information required Drug spilt Liquid/powder 5. For hospital staff, contact the occupational health department. EYE CONTAMINATION WAHT-PHA-002 Page 6 of 10 Version 2.5
1. MITOMYCIN- Rinse the eye thoroughly with copious amounts of Sodium Bicarbonate 8.4%solution holding the eye open. 2. ALL OTHER CYTOTOXIC PRODUCTS- Rinse thoroughly with copious amounts of water for 15minutes, holding the eye open. 3. Seek medical advice immediately. 4. Complete a Datix incident report to include all standard information required a. Drug spilt b. Liquid/powder 5. For hospital staff, contact the occupational health department. 6.2 Dissemination Copy of policy available within all spill kits, document finder and linked to the oncology and haematology home page on the intranet. 6.3 Training and awareness Pharmacy department- as part of staff training plan Nursing Staff- as part of unit induction 7. Monitoring and compliance Review of handling of cytotoxic spillage after the event, by lead pharmacist or lead technician. STANDARDS % CLINICAL EXCEPTIONS Spillage policy followed for 100% NONE all cytotoxic spillages Correct containers used for 100% NONE all cytotoxic waste following spillage Datix form completed with all details 100% NONE 8. Policy Review On a 2 yearly basis by the lead pharmacist cancer and aseptics (AH or WRH) 9. References MARCH panel (Graham Sewell).June 2007:MARCH guideline: Spillages: management and containment. MARCH panel (Graham Sewell) June 2007:MARCH guideline: Personal protective equipment (PPE): selection and use. COSHH data sheets (multiple manufacturers) 10.4 Approval process Approval by medicines safety committee. 10.3 Equality requirements See below WAHT-PHA-002 Page 7 of 10 Version 2.5
Supporting Document 1 - Equality Impact Assessment Tool To be completed by the key document author and attached to key document when submitted to the appropriate committee for consideration and approval. 1. Does the policy/guidance affect one group less or more favourably than another on the basis of: Race Ethnic origins (including gypsies and travellers) Nationality Gender Culture Religion or belief Sexual orientation including lesbian, gay and bisexual people Age 2. Is there any evidence that some groups are affected differently? 3. If you have identified potential discrimination, are any exceptions valid, legal and/or justifiable? 4. Is the impact of the policy/guidance likely to be negative? Yes/ 5. If so can the impact be avoided? N/A 6. What alternatives are there to achieving the policy/guidance without the impact? 7. Can we reduce the impact by taking different action? N/A N/A Comments WAHT-PHA-002 Page 8 of 10 Version 2.5
Supporting Document 2 Financial Impact Assessment To be completed by the key document author and attached to key document when submitted to the appropriate committee for consideration and approval. Title of document: 1. Does the implementation of this document require any additional Capital resources 2. Does the implementation of this document require additional revenue Yes/ 3. Does the implementation of this document require additional manpower 4. Does the implementation of this document release any manpower costs through a change in practice 5. Are there additional staff training costs associated with implementing this document which cannot be delivered through current training programmes or allocated training times for staff Other comments: ne WAHT-PHA-002 Page 9 of 10 Version 2.5
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