Safe Handling of

Cytotoxic
Adopted from course of safe handling cytotoxic

www.aphon.org/.../WoyceSafehandlingNon-CancerCourse3-0...

 Cytotoxic Agents - substances used in the treatment of

malignant and other diseases. They are designed
to destroys rapidly growing cancer cells. They have been
shown to be mutagenic, carcinogenic and/or
teratogenic, either in treatment doses or animal and
bacterial assays
Cytotoxic - an agent or process that is toxic to cells
Chemotherapy - The use of any chemical agents to treat
or control disease. Most often used to describe
treatment of malignant and other diseases with
cytotoxic agent.
Mutagenic - capable of causing alterations/damage to
genes
Carcinogenic - capable of causing cancer
Safe Handling

Objectives
At the completion of this session the
participant will be able to:
Describe the occupational exposure risks of
chemotherapy/biotherapy
List components of safe handling and
disposal practices
Identify components of personal
protection equipment
Safe Handling

Introduction
Chemotherapeutic agents are used successfully to
treat a variety of malignancies - these agents may
also cause malignancy in individuals who handle
them
The Occupational Safety and Health Administration
(OSHA) (1995), reports that safe levels of
occupational exposure to cytotoxic agents cannot
be determined and no reliable method of
monitoring exists

Safe Handling

Introduction
The National Institute for Occupational Safety and Health
(NIOSH) reports in studies that there is evidence of health
risk, and safe levels of exposure to cytotoxic agents have
not been determined by a reliable method (NIOSH,
2004).
Biotheraputic agents also can be associated with
exposure risks. OSHA also has classified them as
hazardous materials Use safe handling for any biotherapy
agent labeled hazardous by the manufacturer or OSHA
(e.g., interferon) (NIOSH, 2004).

Safe Handling

Occupational Exposure
Risk
Health care workers handling chemotherapy
and biotherapy agents are at risk for
occupational exposure to these toxins, and
the long-term effects are unknown

Safe Handling

Occupational Exposure
Risk
The potential health risks include:

Carcinogenicity
Genotoxicity
Teratogenicity
Organ toxicity
Acute symptoms such as headache, nausea, dizziness and skin, eye or
throat irritation
(Valanis, Vollmer, Labuhn, & Glass, 1993)

Safe Handling

Occupational Exposure
Risk
The potential routes of exposure are

Injection through needle stick

Ingestion: direct or through food or beverage
Inhalation of drug by aerosolization
Absorption through mucous membranes after direct contact

Safe Handling

Safe Handling Policy

Protection measures must include at a minimum:
Safe administration, storage, transport and disposal of hazardous agents
Provision of mandatory training of employees regarding hazardous materials
Monitoring of long term occupational exposure and minimization of
employee risk
Hazardous drug spill management

Safe Handling

 prepared by Oncology Pharmacy in accordance with

the guideline
Preparations will be packaged as required for direct
administration to the patient and should not be further
modified. All cytotoxic agents should be labelled with purple
cytotoxic warning labels.
packaged in a sealed, leak-proof container, with outer bags
heat-sealed where possible. The container should protect the
agents from breakage in transit, contain leakage if breakage
occurs and have a childproof lid.
Transported in sealed impervious containers resistant to
breakage.
Clearly marked storage areas must be available for all cytotoxic
agents. Safe storage areas must be designed to minimise the
risk of breakage and to contain spills.
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Safe Handling Policy

Protection measures must include at a minimum:
Prohibition of eating, drinking, chewing gum, storing
food, and applying cosmetics in areas where
cytotoxic/biologic agents are prepared or administered
Provision of protection for employees who are pregnant,
breast-feeding or planning a pregnancy
Monitoring compliance with the above indicated
institutional policies and procedures

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Exposure Protection Guidelines-Personel

Person must be trainned to ensure the protection of the
operator, the environment and the patient.
PPE includes:
Gloves
Gowns
Face shield or goggles

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Exposure Protection Guidelines

Personal Protective Equipment (PPE) is to be used
whenever there is a possibility of cytotoxic/biologic
agents being released into the environment. This
includes:
Preparing or transferring
medications from vials, or
ampoules; spiking, priming
or changing IV
equipment
Expelling air or transferring
medications using needles
or syringes
Contact with leaking tubing or connection sites
Managing cytotoxic spills
Disposing of cytotoxic/biologic agents and mixing materials
When handling the body fluids of a patient for 48 hours after they
receive chemotherapy

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Exposure Protection Guidelines

Labeling and Storage
Medications must be
clearly labeled for
content and
hazardous
nature
Material Safety Data
Sheets (MSDS) must
be
available for all medications
Any area that contains chemotherapeutic materials must be
inaccessible to children with locked entry

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Exposure Protection Guidelines

Administration:
Obtain medication
Wash hands and don PPE
Place a sterile, plastic-backed absorbent pad on the work
surface
Always work below eye level
Ampoules: wrap absorbent sterile pad around the neck of
the ampoule and break away from yourself. Use a filtered
straw for withdrawal

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Exposure Protection Guidelines

Administration:
Packaged medications, oral tablets and capsules: avoid
aerosolization, which results from pressure. Use venting
devises to release the pressure. Capsules and tablets
should be crushed under a BSC
Wear gloves when mixing agents that cause skin or other
irritation (e.g., rituximab).
Do not overfill syringes to prevent the plunger from
separating

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Exposure Protection
Guidelines
Administration:
Excess medication or air contained within a
needleless syringe should never be expressed into
the air, but should instead be expressed directly
into a sterile gauze pad that is placed in a sealable
plastic bag
Sterile technique should be maintained
throughout parenteral drug preparation

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Exposure Protection
Guidelines
Administration:
IV tubing should be primed under a hood or be
primed with 10-20ml of compatible solution using
the backflow method
IV tubing should have Luer-lock connections
Wipe the tubing or syringe with moist gauze then
place in a sealable plastic bag for transport

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Safe Handling

Exposure Protection Guidelines

Administration:
An absorbent pad with a plastic back is necessary
for collecting any spill that may occur when
connecting the tubing to the patient
A cytotoxic medication caution label is attached to
the IV set for the duration of the
chemotherapeutic/cytotoxic/biologic agent infusion

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Exposure Protection Guidelines

Administration:
After administration, remove the IV bag with the tubing attached
(NIOSH, 2004). Do not remove the spike from the bag or reuse
the tubing.
Dispose of all equipment that has come in contact with the
hazardous drug by placing the equipment in a container labeled
cytotoxic waste.
Use detergent and water to clean surfaces that have been in
contact with hazardous drugs (Polovich, 2004).
Remove and discard PPE
Wash your hands before leaving the preparation and
administration area

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Exposure Protection Guidelines

Disposal Guidelines
Hazardous medical waste containers must be available
in all areas where hazardous medications are prepared
and administered (NIOSH, 2004).
The waste containers should
be punctureproof, have a
secure lid, and be clearly
labeled as hazardous waste.

Unused medicine returned

Safe Handling

to pharmacy

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Exposure Protection
Guidelines
Body Fluid Guidelines
Utilize PPE and standard universal precautions
when handling patients body fluid or lines for 48
hours after administration of chemotherapy
Patients may use regular bathroom facilities

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Exposure Protection
Guidelines
Body Fluid Guidelines
Diapers should be disposed of in the same manner
as other hazardous waste by placing them in
appropriately labeled plastic hazardous waste
bags
Bedpans, hats, urinals and emesis basins that are
rinsed carefully with soap and water may be
reused. After use, they should be discarded in the
hazardous waste receptacle.

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Exposure Protection
Guidelines
Body Fluid Guidelines
Linens that are contaminated with body fluids
should be placed in a plastic bag and labeled as
contaminated by chemotherapy before placing
them with other hospital laundry
The toilet should be flushed twice with the lid
down after disposing of excreta from these
patients for 48 hours following chemotherapy
administration
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Exposure Protection
Guidelines
Spill Guidelines
Spill kits should be available in all areas where cytotoxic drugs
are stored, prepared, transported, and administered
Only trained personnel with appropriate PPE should clean up
cytotoxic spills

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Spill management
isolate area and place signs if required
allocate responsibility for managing the spill
contain and soak up the spill using dry absorbent material
wash area with copious amounts of alkaline detergent
rinse area thoroughly with water
dry area with absorbent material
discard all waste into purple cytotoxic waste container
remove personal protective equipment, discard into purple
cytotoxic waste container
wash hands thoroughly with soap and water
complete an incident report
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Waste Management
Equipment
sharps should be disposed of in purple cytotoxic sharps waste
containers
disposable equipment should be disposed of in purple cytotoxic waste
buckets
nondisposable equipment should be washed with copious amounts of
hot soapy water
Excess agents
cytotoxic agents that have not been administered must be returned
intact to pharmacy for disposal
unused portions of cytotoxic agents should be disposed of in purple
cytotoxic waste buckets

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Contaminated linen and clothing

wear personal protective equipment; gown and gloves,
when handling soiled linen and clothing
place contaminated hospital linen in a alginate bag at the
point of contamination, then place in the regular linen
skip for subsequent laundering
contaminated personal linen and clothing must remain
separate from other items of clothing
wash soiled items twice using detergent and hot water,
rinse well
following rinsing the items may be washed with other
articles of clothing
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Waste management
Cytotoxic Waste Disposal
All cytotoxic waste containers should be sealed prior to
collection by domestic services. Cytotoxic preparations
must be transported in sealed designated containers and
labelled as cytotoxic waste. Personnel engaged in the
routine handling and transport of cytotoxic waste should
wear industrial work-wear, polyvinyl chloride (PVC)
industrial gloves and safety boots.
Cytotoxic waste should be segregated from other waste
streams. At present incineration is the only acceptable
method for treating cytotoxic waste.
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