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Introduction ⬇

Nurses who prepare and administer hazardous drugs are at risk for 
occupational exposure, which in turn places them at risk for certain types of cancer, including leukemia; infertility and miscarriage; irritation to the skin or eyes; and allergic reactions.1 Factors that affect the risk of exposure include preparing, administering, and disposing of hazardous drugs; the amount of drug prepared; the frequency and duration of drug handling; the potential for absorption; the use of ventilated cabinets; and work practices.2

The risk of experiencing adverse effects increases with the amount and frequency of exposure and poor work practices.1 Following good work practices and using proper personal protective equipment decrease the risk of such exposure.3

Facilities that store, transport, prepare, and administer hazardous drugs should have emergency procedures for handling spills and exposure as part of their overall health and safety program.3 Hazardous drug spill kits should be available wherever chemotherapeutic agents and other hazardous drugs are stored, transported, prepared, or administered.4 All health care facility personnel who work with or handle hazardous drugs should be trained properly in spill cleanup.2

Equipment ⬆ ⬇

Equipment

Hazardous drug precaution sign • disposable, low-permeability, back-closure, hemotherapy-resistant gown • hazardous drug–resistant shoe covers • two pairs of hazardous drug–resistant gloves • face shield • goggles • respirator mask, appropriate for the spilled agent, approved by the National Institute for Occupational Safety and Health (NIOSH), such as fit-tested N95 or powered air-purifying respirator4,5 • disposable scoop for collecting glass fragments • puncture-proof container for glass fragments • heavy-duty utility gloves • absorbent spill pads or absorbent plastic-backed sheets3,4 • disposable towels • absorbent powder • at least two large, heavy-duty, hazardous waste–labeled, sealable, disposable bags • water • facility-approved deactivating and decontaminating agents • small, sealable plastic bag • safety data sheet (SDS) • cleaning agent designed to remove chemicals from stainless steel • Optional: chemical cartridge-type respirator with full face piece.

Preparation of Equipment ⬆ ⬇

Preparation of equipment

Inspect all equipment and supplies. If a product is expired, is defective, or has compromised integrity, remove it from patient use, label it as expired or defective, and report the expiration or defect as directed by your facility.

Spill kits that contain all the materials needed to clean up hazardous drug spills should be available wherever hazardous drugs are located.4,5 Each kit should have sufficient supplies to absorb about 1,000 mL of hazardous drug. Assemble your own kit or use your facility’s commercially prepared kit as appropriate.2,3

Access the SDS for the spilled agent to determine if a chemical deactivator is recommended for use.4

Implementation ⬆ ⬇

Implementation
  • Assess the size of the hazardous drug spill and call for trained assistance, if needed.4 If the spill is large and can’t be contained with two spill kits, call for additional help.2,3
  • Post a hazardous drug precaution sign immediately to warn others of the presence of a hazardous drug spill and to limit access.2,3,4,5
  • Obtain and open a spill kit.2,3,5
  • Put on gloves (inner and outer), a disposable gown, shoe covers, a face shield, goggles, and a respirator mask that’s appropriate for the spilled agent.4 The use of face shields with goggles is recommended because they offer added skin and eye protection. Don’t use eyeglasses or safety glasses with side shields because they don’t offer adequate protection from splashes. Put on a chemical cartridge-type respirator with a full face piece for a large spill.2,3,5
  • Choose the appropriate items in the spill kit to contain the spill.2,3

Spills on Hard Surfaces

  • Pick up any broken glass fragments with the disposable scoop or by hand wearing heavy-duty utility gloves. Place the fragments in a puncture-proof container.2,3,4
  • Place an absorbent spill pad or absorbent plastic-backed sheet over the spill to wipe up a liquid. Use a damp disposable towel to wipe up powder or solids.2,3,4

Spills on Soft Surfaces

  • Pick up any broken glass fragments with the disposable scoop or by hand wearing heavy-duty utility gloves. Place the fragments in a puncture-proof container.2,3,4
  • Use an absorbent powder on the spill following the manufacturer’s instructions. Don’t use absorbent towels.4
  • After the initial cleanup and containment, contact appropriately trained environmental services staff members to vacuum the area to remove the powder using a vacuum with a high-efficiency particulate air (HEPA) filter reserved for hazardous drug cleanup.2,4,6
  • Ensure that the soft surface is cleaned as directed by your facility.4

Spills in a Biological Safety Cabinet (Bsc)

  • Remove any broken glass fragments by hand wearing heavy-duty utility gloves. Place the fragments in a puncture-proof container. Be careful not to damage the fixed-glove assembly in the isolator.2,3
  • Clean up a liquid spill with absorbent spill pads. For a powder or solid spill, use a damp disposable towel. Include the drain spillage trough in washing efforts.2,3,4
  • Thoroughly clean and decontaminate the involved area using a cleaning agent designed to remove chemicals from stainless steel. Refer to the SDS for the cleaning agent, as needed.2,4,7
  • If the HEPA filter has been contaminated by the spill, seal the BSC in a small, sealable plastic bag or plastic sheeting and label it as contaminated equipment.4
  • Schedule a BSC service technician to change the HEPA filter.4
  • Ensure that the BSC isn’t used before the filter has been changed.2,4

Completing the Procedure

  • Place the puncture-proof container holding the glass fragments and all other contaminated materials into a large, heavy-duty, hazardous waste–labeled, sealable, disposable bag. Then seal the bag.2,3,4
  • Place the sealed bag inside another properly labeled hazardous waste bag and leave the outer bag open.
  • Rinse the contaminated area with water and then clean it with facility-approved deactivating and decontaminating agents following the manufacturers’ instructions for use.2,3
  • Rinse the contaminated area with water several more times. Place all materials used for cleanup and containment in disposable hazardous waste bags.2,3
  • Seal the hazardous waste bags and put them in the appropriate container for final disposal as hazardous waste.2,3
  • Remove all personal protective equipment carefully while continuing to wear your inner gloves. Consider all personal protective equipment worn during hazardous drug spill cleanup to be at least minimally contaminated with trace amounts of hazardous material.2,3,5
  • Put all disposable personal protective equipment in an appropriately labeled hazardous waste disposable bag. Then seal the bag.2,3
  • Remove your inner gloves.
  • Contain your inner gloves in a small, sealable plastic bag. Then place that bag in the final container to dispose of as hazardous waste.2,3
  • Dispose of personal protective equipment in the final hazardous waste container as trace- or bulk-contaminated waste, as determined by your facility.4,8
  • Perform hand hygiene.8,9,10,11,12,13,14
  • After the initial cleanup, contact your facility’s environmental services department to reclean the area.2,3
  • Report and document the hazardous drug spill.4,15,16,17,18

Special Considerations ⬆ ⬇

Special considerations
  • When cleaning hazardous drug spills, move from the area of lowest contamination to the area of highest contamination.2,3
  • Before use, inspect your gloves for defects, such as holes or tears. Use only gloves that are permeation-resistant to hazardous agents.8
  • If you have experienced direct skin or eye contact with a hazardous drug during a spill, remove any contaminated clothing immediately and wash the affected skin with soap and water, or flood the affected eye with isotonic eyewash for at least 15 minutes. Then seek medical attention.2,3
  • Send any nonemployee who has been exposed to the hazardous drug spill to your facility’s emergency department for treatment or as directed by your facility. Then fill out your facility’s incident or exposure form.5

Complications ⬆ ⬇

Complications

Exposure to the hazardous drug is a complication of hazardous drug spill management.2,3,4

Documentation ⬆ ⬇

Documentation

Document the name of the hazardous drug and the approximate volume of drug spilled. Objectively describe how the spill occurred, the actions that were taken to manage the spill, and the procedure that was followed. Document the names of health care facility personnel and patients as well as anyone else who was exposed to the drug spill. Also document the names of facility personnel notified of the spill and the departments in which they work.

References ⬆

  1. Centers for Disease Control and Prevention, Department of Health and Human Services. (2004). NIOSH alert: Preventing occupational exposures to antineoplastic and other hazardous drugs in health care settings. https://www.cdc.gov/niosh/docs/2004-165/pdfs/2004-165.pdf (Level VII)
  2. PowerL. A., & CoyneJ. W. (2018). ASHP guidelines on handling hazardous drugs. American Journal of Health-System Pharmacy, 75, 1996–2031. (Level VII)
  3. Occupational Safety and Health Administration. (n.d.). Controlling occupational exposure to hazardous drugs. https://www.osha.gov/hazardous-drugs/controlling-occex (Level VII)
  4. OlsenM. M., et al. (Eds.). (2019). Chemotherapy and immunotherapy guidelines and recommendations for practice. Pittsburgh, PA: Oncology Nursing Society.
  5. United States Pharmacopeial Convention (USP). (2019). USP general chapter 800> Hazardous drugs-Handling in healthcare settings. https://www.usp.org/compounding/general-chapter-hazardous-drugs-handling-healthcare
  6. EsparzaD. M. (Ed.). (2014). Oncology policies and procedures [CD-ROM]. Pittsburgh, PA: Oncology Nursing Society.
  7. LamerieT. Q., et al. (2013). Evaluation of decontamination efficacy of cleaning solutions on stainless steel and glass surfaces contaminated by 10 antineoplastic agents. The Annals of Occupational Hygiene, 57, 456–469. https://academic.oup.com/annweh/article/57/4/456/158082?sid=f8930b35-f5e0-4502-9822-b2f7290f532e (Level VI)
  8. ConnorT. H., et al. (2008). Personal protective equipment for health care workers who work with hazardous drugs. https://www.cdc.gov/niosh/docs/wp-solutions/2009-106/pdfs/2009-106.pdf (Level I)
  9. Centers for Disease Control and Prevention. (2002). Guideline for hand hygiene in health-care settings:

    Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force

    . MMWR Recommendations and Reports, 51(RR-16), 1–45. A https://www.cdc.gov/mmwr/pdf/rr/rr5116.pdf (Level II)
  10. The Joint Commission. (2021). Standard NPSG.07.01.01. Comprehensive accreditation manual for hospitals. Oakbrook Terrace, IL: The Joint Commission. (Level VII)
  11. World Health Organization. (2009). WHO guidelines on hand hygiene in health care: First global patient safety challenge, clean care is safer care. https://apps.who.int/iris/bitstream/handle/10665/44102/9789241597906_eng.pdf?sequence=1 (Level IV)
  12. Centers for Medicare and Medicaid Services, Department of Health and Human Services. (2020). Condition of participation:

    Infection control. 42 C.F.R. § 482.42

    .
  13. Accreditation Association for Hospitals and Health Systems. (2020). Standard 07.01.21. Healthcare Facilities Accreditation Program:

    Accreditation requirements for acute care hospitals

    . Chicago, IL: Accreditation Association for Hospitals and Health Systems. (Level VII)
  14. DNV GL-Healthcare USA, Inc. (2020). IC.1.SR.1. NIAHO® accreditation requirements, interpretive guidelines and surveyor guidance-revision 20.0. Milford, OH: DNV GL-Healthcare USA, Inc. (Level VII)
  15. Centers for Medicare and Medicaid Services, Department of Health and Human Services. (2020). Condition of participation:

    Medical record services. 42 C.F.R. § 482.24(b)

    .
  16. Accreditation Association for Hospitals and Health Systems. (2020). Standard 10.00.03. Healthcare Facilities Accreditation Program:

    Accreditation requirements for acute care hospitals

    . Chicago, IL: Accreditation Association for Hospitals and Health Systems. (Level VII)
  17. The Joint Commission. (2021). Standard RC.01.03.01. Comprehensive accreditation manual for hospitals. Oakbrook Terrace, IL: The Joint Commission. (Level VII)
  18. DNV GL-Healthcare USA, Inc. (2020). MR.2.SR.1. NIAHO® accreditation requirements, interpretive guidelines and surveyor guidance-revision 20.0. Milford, OH: DNV GL-Healthcare USA, Inc. (Level VII)