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Nurses and Hazardous Drug Safety

Hazardous drugs are an ever-present and sometimes invisible threat to the health of nurses. Exposure to hazardous drugs can have significant negative side effects, including skin rashes, genetic damage, reproductive health issues and cancer. Safe handling of hazardous drugs is a key method of reducing health risks for clinical and non-clinical personnel. The National Institute for Occupational Safety and Health (NIOSH) provides employer guidelines on how to minimize hazardous drug risks with set protocols and personal protective equipment (PPE)

Simplivia Nurses Guide Hazardous Drug Safety CSTD

Nurses at Risk

NIOSH updates its list of hazardous drugs every two years. However, the frequency with which new drugs hit the market necessitates ongoing drug evaluation at the clinical level. Departments should utilize drug safety fact sheets and product information to stay current with safe handling information and procedures for hazardous drugs. Today, in the US, approximately 8 million healthcare workers of all types are at risk of exposure to hazardous drugs (NIOSH, 2020). In addition to nurses, this includes pharmacists, physicians, operating room personnel and veterinary care workers.

In a recent study of nurses handling hazardous drugs in a patient-centered setting, protective gear wasn’t used nearly enough. Nurses only wore two pairs of chemotherapy gloves in 40% of incidents, a respirator in just 30% of cases, and eye protection in a mere 20% (Friese, Wong, et al., 2020). However indispensable these hazardous drugs are for patients, they can be toxic at even at low doses, so safety controls are critical for nurse safety when in handling these drugs.

Exposure Prevention Methods

Closed System Drug-transfer Devices (CSTDs), Containment Primary Engineering Control (C-PEC), and administrative measures and controls work in tandem to create a safety-first environment. Nurse can prevent hazardous drug leakage into the environment – whether as vapor, droplets, or aerosols – by using a CSTD. NIOSH defines a Closed System Drug-transfer Device as a drug transfer device that … - mechanically prohibits the transfer of environmental contaminants into the system - and the escape of hazardous drug or vapor concentrations outside the system.

Some cytotoxic drugs linger on surfaces or in the air for long periods of time, potentially harming anyone that comes into contact with them. Many nurses feel that they are experienced and careful, and minimize improper hazardous drug handling. Results of multiple studies across the country prove otherwise. (Conner, DeBord et al., 2010; Conner, Anderson et al., 1999; Friese, McArdle et al., 2015). Even with a bent toward “being careful,” hazardous drug residue can still escape into the environment. Standard IV equipment, for example, is an open-ended system known to leak on occasion. When paired with hazardous drugs, those leaks result in environmental contamination.

NIOSH and The United States Pharmacopeia (USP) General Chapter <797> recommends using CSTDs to minimize occupational exposures to hazardous drugs (ASHP, 2006; U.S. Pharmacopeia, 2008). The successful use of CSTDs to reduce health risks has been extensively studied. CSTD use and adoption has become common, particularly in the last decade. Results of numerous studies reveal a significant reduction in healthcare worker and environmental hazardous drug exposure when hazardous drugs are compounded or administered using CSTDs (Siderov, Kirsa et al., 2010; Sessink, Connor et al., 2011). The International Society of Oncology Pharmacy Practitioners (ISOPP) has also declared the use of CSTDs to be an effective method to prevent hazardous drug contamination during preparation and administration.

Establishing a culture of safety, and following administrative and engineering controls, aids in eliminating outdated practices and harmful habits. NIOSH recommends using PPE in situations where administrative or engineering controls are not enough to prevent risk of exposure. Adhere to these safety guidelines regarding CSTDs:

  • Follow manufacturer's guidelines regarding CSTD usage. Nurses should receive training in the proper procedures and handling techniques to avoid misusing CSTDs and causing accidental contamination.
  • CSTDs are a complementary source of protection. PPE should still be used in accordance with safety recommendations from hazardous drug manufacturers. 

Simplivia Nurses Guide Hazardous Drug Safety CSTD

Closed-System Drug Transfer

IV equipment is designed with the patient’s safety in mind, not the nurses. Results of several studies indicate that hazardous drugs may leak during drug administration while nurses are spiking IV containers or removing tubing (Connor, Anderson et al. 2002). The use of IV equipment developed for hazardous drugs can reduce incidences of leakage. Proper IV containers have a double-membrane system designed to trap aerosols and provide a dry-spike option.

Without a closed-system drug transfer, IV taping is necessary on tube connection sites, unless there is a Luer-lock fitting or the equivalent. Do not use an IV container with venting tubes. In addition, IV sets should be primed at the pharmacy. If primed at the administration site, use a compatible IV fluid before spiking the bag.

Ventilated Cabinets

Ventilated cabinets filter contaminated air through a HEPA system to capture aerosols. This is a practical approach, since most hazardous drugs involve aqueous injections that can generate an aerosol. A HEPA-filtered ventilated cabinet re-circulates some air back into the cabinet and exhausts some outdoors. It is possible that with the development of bioengineered drugs or drugs that utilized nanotechnology, traditional ventilated cabinets will no longer be sufficient to ensure safety.

Simplivia Nurses Guide Hazardous Drug Safety CSTD

Spill Kits and Spill Management of Hazardous Drugs

In the event of a spill, nurses should employ hazardous drug spill kits containing the necessary equipment for safe clean-up. For example:

  • Tyvek gown or coveralls
  • Shoe covers
  • Splash goggles
  • Two pairs chemotherapy-tested disposable gloves
  • Absorbent pads
  • Scoop with detachable scraper for collecting
    glass fragments
  • Two 5-gallon plastic waste disposal bags
  • One Ziploc bag for returning contaminated splash
    goggles to pharmacy
  • Hazardous drug waste labels

Personal Protective Equipment (PPE)

Employers post safe handling methods and procedures, but sometimes departments become lax in their commitment to safety. Choosing a fabric lab coat instead of a disposable gown, or wearing gloves beyond the recommended 30 minutes puts clinical and non-clinical personnel at risk (Conner & McDiarmid, 2006; ASHP, 2006). PPEs are a temporary barrier between hazardous drug contamination and the nurse or other healthcare professional to prevent a health hazard. Contaminated clothing must be never returned to the home.

Glove thickness does not determine dermal safety from hazardous drugs. Exam gloves made from polyvinyl chloride do not protect the wearer from drug exposure
(Wallemacq, Capron et al., 2006). Single gloves are only acceptable during receiving, unpacking, and storing hazardous drugs unless there is a risk of splashes or spills. Look for glove manufacturer test data for permeation resistance compared to hazardous drug chemotherapy glove guidelines (ASTM, 2019).

Disposable gowns offer temporary and partial defense against hazardous drugs. These gowns are an indispensable part of a nurse's protective gear. A lab coat and/or scrubs do not provide the same protection as a disposable gown rated for the task at hand. Gowns should be worn within a C-PEC, whether handling uncoated tablets or compounding hazardous drugs.

Respiratory Protection
Surgical masks are not enough to prevent hazardous drug exposure on their own. An N95 respirator paired with a surgical mask may be allowed for certain hazardous drugs, as listed on the drug information sheet. N95 masks have a shelf life, and over time the nose bridge and strap may degrade, resulting in a risk of exposure for nursing staff. Check mask manufacturer’s storage conditions to ensure stocked respirators are current and stored correctly to ensure the best possible best protection against hazardous drug aerosols and vapors.

Eye and Face Shields
Vapors, aerosols and splashes from hazardous drugs cause irritation and potential long-term damage not only to the eyes but also to other organs. Glasses alone do not provide sufficient protection. Glasses-wearers should choose full-face shields and/or goggles to avoid the risk of hazardous drug exposure.

Sleeve, Hair, and Shoe Coverage
Always check sleeve and shoe covers for holes or other manufacturing defects before entering a potentially harmful area or handling hazardous drugs. When compounding hazardous drugs, double shoe covers are required, and both layers must be removed before leaving a C-PEC.

Personal Protective Equipment Disposal
Disposal of PPE after contact with hazardous materials must be done properly to avoid contamination. Never wear disposable PPE more than once. Adhere to these safety guidelines regarding PPE disposal:

  • View all PPE as contaminated to encourage safe handling.
  • Consider PPE as bulk or contaminated waste, and contain or dispose of the items as per your facility’s procedures (Conner & McDiarmid, 2006).
Simplivia Nurses Guide Hazardous Drug Safety CSTD
1. ASHP Guidelines on Handling Hazardous Drugs, American Journal of Health-System Pharmacy, Volume 63, Issue 12, 15 June 2006, Pages 1172–1191,
2. ASTM D6978-05(2019), Standard Practice for Assessment of Resistance of Medical Gloves to Permeation by Chemotherapy Drugs, ASTM International, West Conshohocken, PA, 2019.
3. Connor, T.H. and McDiarmid, M.A. (2006), Preventing Occupational Exposures to Antineoplastic Drugs in Health Care Settings. CA: A Cancer Journal for Clinicians, 56: 354-365.
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8. Friese, C., Wong, M., Fauer, A., Mendelsohn-Victor, K., Polovich, M., & McCullagh, M. (2020). Hazardous Drug Exposure: Case Report Analysis From a Prospective, Multisite Study of Oncology Nurses’ Exposure in Ambulatory Settings. Clinical Journal of Oncology Nursing, 24(3), 249–255.
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14. Sessink, P. J., Connor, T. H., Jorgenson, J. A., & Tyler, T. G. (2011). Reduction in surface contamination with antineoplastic drugs in 22 hospital pharmacies in the US following implementation of a closed-system drug transfer device. Journal of oncology pharmacy practice: official publication of the International Society of Oncology Pharmacy Practitioners, 17(1), 39–48.
15. Siderov, J., Kirsa, S., & McLauchlan, R. (2010). Reducing workplace cytotoxic surface contamination using a closed-system drug transfer device. Journal of Oncology Pharmacy Practice, 16(1), 19–25.
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17. The United States Pharmacopeial Convention. USP<797> Guidebook to pharmaceutical compounding – sterile preparations. In: The United States Pharmacopeial Convention, Rockville, MD, 2008.
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19. Wallemacq, Ph.D., Pierre E., Capron, M.Sc., Arnaud, Vanbinst, M.Sc., Roger, Boeckmans, Eric, Gillard, Ph.D., Jean, Favier, Pharm.D., Bertrand, Permeability of 13 different gloves to 13 cytotoxic agents under controlled dynamic conditions, American Journal of Health-System Pharmacy, Volume 63, Issue 6, 15 March 2006, Pages 547–556,


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