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Resource Document ­ Safe Handling and Waste Management of Hazardous Drugs ID: 000188 (V.3)
Approved: 30 Sep 2009
Last Modified: 13 Sep 2011
Review Due:21 Dec 2012
This document provides an overview of the safe handling and waste management of hazardous drugs used in the treatment of cancer. It is a requirement that all personnel transporting or administering hazardous drugs or handling anything potentially contaminated with unchanged drug or active metabolites comply with statutory legislation, Workcover guidelines and local institutional policy and procedures. This document should be read in conjunction with: 1.
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Workcover NSW. 2008. Cytotoxic Drugs and Related Waste Guide 1 Worksafe Victoria. 2003. Handling Cytotoxic Drugs in the Workplace 2 Queensland Workplace Health and Safety Strategy. 2006. Guide for Handling Cytotoxic Drugs and Related Waste 3 NHMRC. 2010. Australian Guidelines for the Prevention of Infection in Healthcare 4 NSW Occupational Health and Safety Act 20005 The Occupation Health and Safety Regulation 20016 Cancer Nurses Society of Australia. 2010. Position Statement on the Minimum Education and Safety Requirements for Nurses involved in the Administration of Anti­cancer drugs within the Oncology and Non­Oncology Setting7 Hazardous Drugs The term hazardous describes drugs that require special handling because of the health risks that may result from exposure. These risks are a result of the inherent toxicities of the drugs. According to the Occupational Safety and Health Administration (OSHA), safe levels of occupational exposure to hazardous agents cannot be determined, and no reliable method of monitoring work­related exposure exists. Therefore, it is imperative that those who work with hazardous drugs adhere to practices designed to minimise occupational exposure8. Drugs are considered hazardous if they exhibit one or more of the following six characteristics in humans or animals: 1.
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carcinogenicity, or the ability to cause cancer; a carcinogen genotoxicity, or the ability to cause a change or mutation in genetic material; a mutagen teratogenicity the ability to cause defects in foetal development or foetal malformation; a teratogen and other developmental toxicities that can be manifested at any point in the life span of the foetus reproductive toxicity or fertility impairment serious organ toxicity or adverse health effects at low doses in experimental animal models or treated patients e.g. hypersensitivity reactions structure and toxicity profiles of new drugs that mimic existing drugs determined hazardous by the five previous criteria Hazardous drugs may include cytotoxic, antiviral, antibiotics, immunomodifiers, biological and molecular targeted drugs. Cytotoxic Drugs Cytotoxic drugs disrupt the growth and function of both healthy and cancerous cells, resulting in toxic side effects for treated patients. These non selective actions can also cause adverse effects in health care workers who are inadvertently exposed to these drugs including reproductive and developmental toxicity and an increased risk of cancer. Acute health effects have been reported in the literature where control measures have not been adequate and include: ■
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alteration to normal blood cell count miscarriage and possible malformations in the offspring of pregnant women fertility changes abdominal pain, hair loss, nasal sores and vomiting Page 1 of 13
Resource Document - Safe Handling and Waste Management of Hazardous Drugs
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liver damage ■
contact dermatitis, local toxic or allergic reaction, which may result from direct contact with skin or mucous membranes1 See the link for an overview of epidemiological studies on the Cytotoxic Drugs Biological and Molecular Targeted Therapies ­ Health Effects Related to Occupational Exposure to There is limited data available on the long term effects of biological and molecular targeted therapies. However, many of these agents are considered hazardous and low grade occupational exposure may result in potential health risks: ■
monoclonal antibodies (MoAbs or MABs): may cause reproductive and developmental toxicity. See link for the
Reproductive Effects of Monoclonal Antibodies 9
● may cause immunogenic reactions in healthcare workers e.g. an allergic reaction 10
● the carcinogenic risk has not been evaluated and is unknown
thalidomide an antiangiogenic agent, is a known human teratogen 11 interferon is teratogenic8 Bacillus Calmette­Guerine (BCG) contains live, attenuated mycobacteria. Fatal BCG infections have been reported in health care workers 12 ●
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For further definitions and a comprehensive list of the risks associated with antineoplastic drugs see the link­ Hazardous Drugs Risk Table Minimising Exposure to Hazardous Drugs Occupational exposure to hazardous agents may occur where control measures fail or are not in place. Exposure may be through skin absorption, inhalation of aerosols and drug particles, ingestion from contaminated food or drink or other hand to mouth contact, and needle stick injuries; whilst undertaking any of the following activities: ■
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drug preparation drug administration handling patient waste drug and patient transport spills Identification All cytotoxic materials are universally identified by a purple symbol representing a cell in the late phase of division known as telophase. Hazardous drugs that have the potential to transmit infection should be suitably labelled as per institutional policy e.g. infection control guidelines stipulates that live vaccine and waste products e.g. BCG should be labelled with the following symbol. Preparation Hazardous drug preparation should only be performed in appropriate pharmacy facilities, by trained pharmacy personnel in accordance with the appropriate Society of Hospital Pharmacists (SHPA) standards.13,14 Packaging Hazardous drugs should be packaged in a labelled, sealed leak proof container with the outer bag heat sealed where possible. Page 2 of 13
Resource Document - Safe Handling and Waste Management of Hazardous Drugs
Storage Hazardous drugs should be stored in a hard walled and robust container, securely closed and labelled with appropriate warnings. Refrigerate as necessary. Transportation Hazardous drugs that are to be transported should be placed in a hard walled and robust container securely closed and labelled with appropriate warnings. A spill kit should always accompany hazardous drugs that are transported. Disposal After use, all hazardous drug waste and related equipment should be double bagged into the appropriate clinical waste bag. Purple bags with the telophase symbol are used for drugs and related waste that are cytotoxic. Waste should then be disposed of into the appropriate hazardous waste bin. For cytotoxic waste discard into a purple cytotoxic waste bin that has a sealable lid. For other hazardous waste such as BCG discard into a yellow hazardous waste bin. Page 3 of 13
Resource Document - Safe Handling and Waste Management of Hazardous Drugs
Cleaning It is important that all areas exposed to hazardous drug related waste and associated equipment (e.g. toilets, patient chairs and infusion pumps) are thoroughly cleaned daily with soap and water. Cleaning solutions that are alcohol based can bind to some types of hazardous drugs and spread the area of contamination 26. For hazardous drugs that are infectious e.g. BCG, contaminated areas should be cleaned initially with soap and water followed by cleaning with a sodium hypochlorite solution.4 For recommended cleaning solutions please see link Cleaning Solutions for Hazardous Drug Spills Eating and Drinking Avoid eating and drinking in areas where hazardous drugs are prepared and administered as there is a risk that food and drink can be contaminated and then ingested. Personal Protective Equipment (PPE) Personal protective equipment (PPE) must be worn when handling and administering hazardous drugs and related waste. Hands should be washed with soap and water before and after wearing PPE. NOTE: Alcohol based hand washing preparations do not eliminate chemical contamination. Gowns Gowns should: ■
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be made of a lint free, impermeable material e.g. bonded polyethylene fibre have a closed front the sleeves need to be long and elasticised at the wrist 15 gowns should be changed after use, or immediately if overt contamination occurs care must be taken when removing gowns to reduce the risk of surface and personal contamination gowns should not be worn in non clinical areas e.g. offices, tea rooms non­disposable gowns should be double bagged and processed through an appropriate laundry facility Protective Eye Wear ■
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must be optically clear, antifog, distortion free, close fitting and shielded at the side must comply with Australian Standards AS/NZ199216and AS/NZ 1336 (1997)17 should be cleaned with warm soapy water and allowed to air dry after each use in the event of overt contamination eye wear should be disposed off NOTE: It is recommended that a risk assessment be completed for all staff who wears glasses, as they may require additional protection. The completed risk assessment should be taken into account in the selection and fitting of protective eye wear.1 Respiratory Protective Equipment (RPE) ■
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required to protect staff from inhalation of aerosolised hazardous drug a particulate respirator P2/N95 is recommended NOTE: Staff should have a fit test performed on commencement of employment and then annually to ensure that the size of the mask to be used is correct. For information on fit testing please see Australian/New Zealand Standards AS/NZS 1715­1994 selection use and maintenance of respiratory protective devices.18,19,20 Page 4 of 13
Resource Document - Safe Handling and Waste Management of Hazardous Drugs
Staff should also ensure that masks are worn correctly by performing a fit check each time they are worn. See Table 1. Table 1 Fit Checking
Procedure for applying and fit checking RPE Image © NHMRC 4 2010
Confirm correct fitting by checking: ■
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the positive pressure seal of the respirator by gently exhaling. If air escapes, the respirator needs to be adjusted the negative pressure seal of the respirator by gently inhaling. If the respirator is not drawn in towards the face, or air leaks around the face seal, readjust the respirator and repeat process, or check for defects in the respirator 4 Overshoes ■
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should be made of impervious material with skid resistant plastic soles should be worn when cleaning a hazardous drug and related waste spill Page 5 of 13
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Gloves Gloves should: ■
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be made of materials that minimise drug permeability e.g. nitrile, polyurethane or neoprene be powder free. Powder may absorb contaminants, leading to aerosolisation and an increased risk of touch contamination be long enough to cover gowns when the wearers arm is stretched out fully All gloves have some degree of permeability to hazardous drugs. This permeability increases over time. Standard surgical, vinyl and latex gloves should not be used as they do not provide the required level of protection due to drug and or carrier permeability.21,22 Gloves should be changed: ■
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at the end of a procedure prior to contact with another patient in the event of contamination if they become punctured or torn in accordance with manufacturers instructions and permeability studies, or at intervals of 30 minutes NOTE: Gloves must be worn when handling the outside of a drug bag or syringe as there is a high likelihood of hazardous drug surface contamination that can be absorbed dermally and/or be spread to other surfaces i.e. pumps Workcover, NSW recommends the use of one pair of chemoprotectant gloves for safe administration and handling of cytotoxic drugs, except in the event of a cytotoxic spill where double gloving is required. However, international cancer agencies such as ISOPP 23, NIOSH24, and ONS25 now recommend that all staff double glove with chemoprotectant gloves for all procedures. See Table 2 for the recommended order for the putting on and removal of PPE and Table 3 for the procedure to correctly remove gloves if the gown is left on. Table 2
Order of Putting on PPE if Wearing One Pair of Gloves
Order of Removing PPE if Wearing One Pair of Gloves 1. Perform hand hygiene.
1. Remove gloves.
2. Put on gown.
2. Perform hand hygiene.
3. Put on face protection, mask and protective eyewear.
3. Remove Gown.
4. Put on pair of gloves over the cuff of the gown.
4. Remove face protection, mask and protective eyewear.
5. Perform hand hygiene with soap and water.
Order of Putting on PPE if Wearing Two Pairs of Gloves
Order of removing PPE if Wearing Two Pairs of Gloves
1. Perform hand hygiene.
1. Remove outer glove.
2. Put on inner pair of gloves.
2. Remove gown.
3. Put on gown. Inner gloves should be under the cuff of the gown).
3. Remove face protection, mask and protective eyewear.
4. Put on face protection, mask and protective eye wear.
4. Remove inner gloves.
5. Put on outer pair of gloves (over the cuff of the gown).
5. Perform hand hygiene with soap and water.
NOTE: In the event of a hazardous drug spill staff should put on respiratory protective equipment. See Clinical procedure for the Management of
a Hazardous spill.
Table adapted from ASSTSAS 200826 Page 6 of 13
Resource Document - Safe Handling and Waste Management of Hazardous Drugs
Table 3
Safe Removal of the Two Outer Pair of Gloves over the Cuff of the Gown (if the gown is left on) Grasp the outer glove on hand 1 with hand 2 and pull off, touching only the outside of the glove, in
order to avoid contaminating the inner pair.
Pull off outer glove 2 with hand 1, touching only the inside of the glove.
Safe Removal of the Inner Pair of Gloves under the Cuff of the Gown (if the gown is kept on)
Pull on the gloves to free them from the cuffs of the gown. Touch only the outside of the gloves.
With glove hand 1, remove the glove on hand 2, by grasping it on the outside.
With bare hand 2, insert the fingers under the cuff of the remaining glove and remove it.
Table adapted and Images© adapted from ASSTSAS 200826
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Closed System Drug Transfer Device (CSTD) Closed system drug transfer devices (CSTD) used in drug preparation and administration have been designed to allow for the containment of aerosolised or vaporised drug while limiting the potential for direct skin contact or inhalation from the inadvertent release of the drug to the environment. Several studies have clearly demonstrated the efficacy of using these systems in reducing environmental contamination when used with existing measures compared to standard techniques 27,28. NSW Workcover1 and international agencies such as ISOPP 23, ONS25 and NIOSH29 recommend using a containment system (closed system) to minimise the risk of hazardous drug exposure in the workplace. Handling Body Waste Hazardous drugs are primarily eliminated from the patient by renal and hepatic excretion. All body substances may be contaminated with either the unchanged drug or active drug metabolites. Exposure to hazardous substances may occur through: ■
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the handling of vomit, blood, excreta and fluid drained from body cavities the handling of bedpans, urinals, emptying urinary catheter bags, colostomy/urostomy bags and vomit bowls the handling of bed linen or clothing soiled with patient waste, or potentially contaminated with the hazardous drug the touching or handling of contaminated surfaces cleaning up of hazardous spills The period during which body substances may be contaminated with drug metabolites following treatment will differ for individual drugs and patients. See the following link to Drug Excretion Times Table It is recommended that: ■
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full PPE is worn for a seven day period from the completion of treatment when handling patient body fluids unless otherwise indicated. Drug Excretion Times Table for drugs that have an extended elimination the date of drug administration and length of time for PPE is documented in the patients medical record staff are careful to avoid splashes and spills an indwelling catheter is used for incontinent patients urine is not decanted into a jug for measurement due to the risk of aerosol contamination. Urine required to be measured should be: ● weighed, or ● measure using a witches hat (disposable toilet and pan liners); the type used must be leak proof and show volume measurement appliances such as colostomy, ileostomy or urostomy bags, urinary catheters or incontinence aids, disposable nappies and heavily exuding dressing materials are double bagged prior to weighing and placed into the appropriate cytotoxic/hazardous waste bin.1 Page 8 of 13
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Image of a witches hat Toilets It is recommended dedicated toilets be allocated to patients receiving hazardous drugs. Men should be instructed to be seated when urinating to reduce the risk of splashes and aerosol contamination. Patients should be instructed to close the toilet lid and to use a full flush.1 When a lid is not present, consider covering the open toilet with a plastic­backed liner prior to flushing to prevent splashing. NOTE: For patients treated with intravesicular Bacillus Calmette­Guerine (BCG) 1 sachet of sodium hypochlorite or 2 cups of household bleach must be placed in the toilet after voiding. The toilet must be left for 15 minutes prior to flushing. The patient must repeat this procedure for every void for the first 6 hours after instillation. Contaminated Linen Management is dependant on the type of and the amount of contamination: ■
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for small areas of contamination linen should be double bagged into a leak proof bag for laundering grossly contaminated linen should be double bagged and discarded into an appropriate cytotoxic/hazardous waste bin linen contaminated with blood or BCG should be double bagged, labelled as infectious and discarded into an appropriate cytotoxic/hazardous waste bin 4 For patients at home: ■
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linen contaminated with hazardous drug should be washed separately, with warm water on a full length cycle and allowed to air dry linen contaminated with BCG should soaked in household bleach (sodium hypochlorite) for approximately 20 minutes and then washed separately, with warm water on a full cycle and allowed to air dry Septic Tanks The impact of drugs and chemicals on waste water treatment and alternative household waste disposal systems is a contentious issue. Anecdotal evidence suggests that there is some effect on the biological performance of aerobic waste water treatment systems, but the full effect is unable to be quantified. It is considered unlikely that systems not using water would dilute the contaminated waste sufficiently to remove the risk of exposure. In waterless systems, dry compost is normally buried with a 100mm soil cover and liquid waste is directed into a subsoil trench. If there is a risk of these systems being contaminated with hazardous drugs and related waste, it is recommended that home owners seek the advice of the supplier with respect to the effect of these drugs and chemicals on their particular system. For maintenance and emptying of systems contaminated with hazardous drugs and related waste, PPE is recommended to reduce the risk of exposure. 2 Spill and Accidental Exposure Management Spills of hazardous drugs and related waste must be dealt with immediately as they present a health risk to those exposed. Spills may occur in all areas where hazardous drugs and related waste are handled, stored, transported and disposed. Spill kits should be clearly labelled and available: ■
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in all areas where hazardous drugs are administered when transferring patients who have hazardous drugs in situ or where body fluids are still deemed to be contaminated with the less active metabolites on the transport of hazardous drugs from the pharmacy to the treatment area and from ward storage area to the bedside Contents of spill kit should include: Page 9 of 13
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instructions for use or standard operating procedure for the management of a spill cytotoxic/hazardous drug spill sign personal protective equipment (PPE) e.g. ● single use chemoprotectant gloves x 2 ● impermeable chemotherapy gown ● protective eyewear ● P2 or P45 Mask ● overshoes absorbent materials e.g. ● chemical absorbent spill pillow ● chemical absorbent mat(s) ● chemical absorbent granules a small scoop or scraper to collect any glass fragments hazardous/cytotoxic waste bag(s) and bin cleaning agents ● hospital approved detergent ● water for a powder spill ● 1 in 50 dilution of 5 % sodium hypochlorite solution or if not available Granular chlorine e.g. Det­Sol or Diver sol, to be diluted as per manufacturers instructions incident report form(s) Community Care Settings ■
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a patient who is treated at home or in a community care setting should be provided with a spill kit with easy to read instructions the kit should include a list of contents, and information on the replacement and disposal of used items Spill Management ■
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all spills should be managed as per Workcover and institutional guidelines see link to Clinical Procedure ­ Hazardous Drug Spill Management an incident report should be completed covering: ● full details of the incident and staff involved ● immediate first aid provided e.g. washing and removal of contaminated clothing ● details of PPE worn ● the full name of the drug involved and the individual components including diluents ● health surveillance of workers involved in the incident NOTE: it is mandatory in NSW that Workcover is notified of all personnel involved in a spill with cyclophosphamide Accidental Contamination ■
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immediately remove personal protective equipment (PPE) and/or contaminated clothing check the material data sheet for appropriate first aid measures for skin and mucosal exposure immediately flush/wash the affected area ● an eye injury should be treated with a continuous irrigation of sodium chloride 0.9% for at least 15 minutes (may be facilitated by using an intravenous infusion set) for penetrating injuries ● wash the affected skin with soap and clean thoroughly with copious amounts of water ● do not administer anaesthetic drops or ointments seek immediate medical advice and further medical attention as necessary Health Surveillance International cancer agencies such as ISOPP 23, NIOSH24 and ONS25 recommend that all staff whose responsibilities involve cytotoxic drug administration/preparation should receive at baseline and then at a minimum of six monthly intervals:­ ■
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a general and reproductive health questionnaire full blood examination Page 10 of 13
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urinalysis liver function and transaminase test This information may then be used to compare any subsequent health surveillance which is undertaken either routinely or following accidental exposure. A physical examination should be performed at the time of employment and then as required for any workers whose health questionnaire or blood work indicates an abnormal finding. For further information on health surveillance refer to Workcover Guidelines.1,2,3
Family Planning, Pregnancy and Breast Feeding A recent survey of more than 3000 oncology nurses showed that those who administer chemotherapy before and during pregnancy were 2.3 to 5 times more likely to give birth prematurely and/or have children with learning disabilities, especially language and motor problems.30 Staff, who are pregnant or breast feeding and/or who are trying to conceive should be permitted to avoid working with hazardous drugs during this period. Such staff should be given alternative tasks or be rostered to another work area. 1 Patient Education Patient Education should cover: ■
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the safe handling and waste management of hazardous drugs containing waste that is generated from drug administration in the home i.e. ● keeping waste containers secure and appropriately labelled ● to sit when going to the toilet and to close the lid and fully flush using and disposing of incontinence aids, colostomy, ileostomy bags, disposable nappies handling and the washing of contaminated linen Patients and family/carers should be supplied with
Patient information and 24 hour medical and nursing contact details. Patients on home ambulatory chemotherapy should also be provided with: ■
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appropriate equipment a spill kit with instructions on how to clean up a spill References 1.
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Workcover NSW. 2008. Cytotoxic Drugs and Related Waste Guide 2008. New South Wales Government ­ Link to external article Worksafe Victoria.2003."Handling cytotoxic drugs in the workplace". Queensland Workplace Health and Safety Strategy.2006. Guide for handling cytotoxic drugs and related waste NHMRC 2010. Australian Guidelines for the Prevention and Control of Infection in Healthcare. Australian Commission on Safety and Quality in Health care. Australian Government 2010 2000."Occupational Health and Safety Act" 2001. "Occupational Health and Safety Regulation" Cancer Nurses of Australia. 2010. Position Statement on the Minimum Education and Safety Requirements for Nurses involved in the Administration of Drugs. Created: July 2003. Reviewed: April 2010. ­ Link to external article OSHA [1999]. OSHA Technical Manual (OTM), TED 01­00­015 (TED 1–0.15A), Washington, DC: U.S. Department of Labor, Occupational Safety and Health Administration last downloaded 20/12/2010 www.osha.gov/dts/osta/otm/otm_toc.html Langford, S.Fradgley,S.Evans.M et al,2008 "Assessing the risk of handling monoclonal antibodies." Hospital Pharmacist. (15) 60­64. Halsen, G. and Kramer, l. 2011 Assessing the risk to health care staff from long­term exposure to anticancer drugs­the case of monoclonal antibodies. J Oncol Pharm Pract. 2011 Mar;17(1):68­80. Epub 2010 Jul 28. ­ Link to external article Celgene Pty Ltd. Product Information. Thalidomide Pharmion 50mg Hard Capsules. Date of TGA Approval or Last Amendment: 13 March 2008 BCG Vaccine and Consumer Medicine Information: Connaught Laboratories: Canada. 2002. The Society of Hospital Pharmacists of Australia Committee of Speciality Practice in Oncology. Standards of Prctice for the Provision of Clinical Oncology Pharmacy Services. J Pharm Prac Res 32(2):115­18. 2004. The Society of Hospital Pharmacists of Australia Committee of Specialty Practice in Oncology. Standards of Practice for the Safe Handling of Cytotoxic Drugs in Pharmacy Departments J Pharm Pract Res 35(1):44­52 AS 2013­1989 Cleanroom garments – Product requirements AS/NZ (1992) and Amendment 1 (1994) Eye protectors for industrial application AS/NZS 1336 (1997) Recommended practices for occupational eye protection AS/NZS 1715­1994 Selection, use and maintenance of respiratory protection devices AS/NZS 1716­1994 Respiratory protective devices AS/NZS 1716­1994/Amdt1­1996 Respiratory protective devices Page 11 of 13
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89168­017­2 www.asstsas.qc.ca Siderov, J., S. Kirsa and R. McLauchlan. 2010. "Reducing workplace cytotoxic surface contamination using a closed­system drug transfer device." J Oncol Pharm Pract 16(1):19­25. Sessink, P. J., T. H. Connor, J. A. Jorgenson and T. G. Tyler. 2011. "Reduction in surface contamination with antineoplastic drugs in 22 hospital pharmacies in the US following implementation of a closed­system drug transfer device." J Oncol Pharm Pract 17(1):39­48. NIOSH Alert. 2004"Preventing occupational exposures to antineoplatic and other hazardous drugs in health care settings" US Department of Health & Human Services, Public Health Service, Centres for Disease Control and Prevention, National Institute for Occupational Safety and Health, DHHS (NIOSH Publication No 2004­165). Fransman, W., N. Roeleveld, S. Peelen, et al. 2007. "Nurses with dermal exposure to antineoplastic drugs: reproductive outcomes." Epidemiology 18(1):112­119. ­ Link to external article ASHP 2006. ASHP guidelines on handling hazardous drugs. Am J Health­Syst Pharm 63:1172–1193. Blair, A., T. Zheng, A. Linos, P. A. Stewart, Y. W. Zhang et al. 2001. "Occupation and leukemia: a population­based case­control study in Iowa and Minnesota." Am J Ind Med 40(1):3­14. NIOSH 2010. NIOSH List of Antineoplastic and Other Hazardous Drugs in Healthcare Settings 2010 Cincinnati, OH: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health, DHHS (NIOSH) Publication Number 2010­167 September 2010 Valanis, B. G., W. M. Vollmer, K. T. Labuhn et al. 1993. "Acute symptoms associated with antineoplastic drug handling among nurses." Cancer Nurs 16(4):288­295. Valanis, B., W. Vollmer, K. Labuhn, et al. 1997. "Occupational exposure to antineoplastic agents and self­reported infertility among nurses and pharmacists." J Occup Environ Med 39(6):574­580. 2007. The Society of Hospital Pharmacists of Australia Committee of Speciality Practice in Cancer Services. Standards of Practice for the transportation of Cytotoxic Drugs from Pharamcy Departments J Pharm Pract Res 37 (3):234­5. McDiarmid, M. and T. Egan. 1988. "Acute occupational exposure to antineoplastic agents." J Occup Med 30
(12):984­987. Gullo, S. M. (1988). "Safe handling of antineoplastic drugs: translating the recommendations into practice." Oncol Nurs.Forum. 15(5): 595­601. Jagun, O., M. Ryan and H. A. Waldron. 1982. "Urinary thioether excretion in nurses handling cytotoxic drugs." Lancet 2(8295):443­444. ­ Link to external article Norppa, H., M. Sorsa, H. Vainio, et al. 1980. "Increased sister chromatid exchange frequencies in lymphocytes of nurses handling cytostatic drugs." Scand J Work Environ Health 6(4):299­301. Petralia, S. A., M. Dosemeci, E. E. Adams and S. H. Zahm. 1999. "Cancer mortality among women employed in health care occupations in 24 U.S. states, 1984­1993." Am J Ind Med 36(1):159­165. Rix, B. A. and E. Lynge. 1996. "Cancer incidence in Danish health care workers." Scand J Soc Med 24(2):114­120. Sotaniemi, E. A., S. Sutinen, A. J. Arranto, et al. 1983. "Liver damage in nurses handling cytostatic agents." Acta Med Scand 214(3):181­189. ­ Link to external article Fransman, W., R. Vermeulen and H. Kromhout. 2005. "Dermal exposure to cyclophosphamide in hospitals during preparation, nursing and cleaning activities." Int Arch Occup Environ Health 78(5):403­412. ­ Link to external article Arrington, D. M. and M. A. McDiarmid. 1993. "Comprehensive program for handling hazardous drugs." Am J Hosp.Pharm. 50(6):1170­1174. Connor, T. H., J. L. Laidlaw, J. C. Theiss, et al. 1984. "Permeability of latex and polyvinyl chloride gloves to carmustine." Am J Hosp.Pharm. 41(4):676­679. Fransman, W., D. Huizer, J. Tuerk, et al. 2007. "Inhalation and dermal exposure to eight antineoplastic drugs in an industrial laundry facility." Int Arch Occup Environ Health 80(5):396­403. ­ Link to external article Anderson, R. W., W. H. Puckett, Jr., W. J. Dana, et al. 1982. "Risk of handling injectable antineoplastic agents." Am J Hosp Pharm 39(11):1881­1887. ­ Link to external article Chrysostomou, A., R. Seshadri and A. A. Morley. 1984. "Mutation frequency in nurses and pharmacists working with cytotoxic drugs." Aust N Z J Med 14(6):831­834. Skov, T., B. Maarup, J. Olsen, M. Rorth, H. Winthereik and E. Lynge. 1992. "Leukaemia and reproductive outcome among nurses handling antineoplastic drugs." Br J Ind Med 49(12):855­861. Solimando, D. A., Jr. and J. P. Wilson (1983). "Demonstration of skin fluorescence following exposure to doxorubicin." Cancer Nurs 6(4): 313­5. ­ Link to external article Hirst, M., S. Tse, D. G. Mills, et al. 1984. "Occupational exposure to cyclophosphamide." Lancet 1(8370):186­188. Fransman, W., R. Vermeulen and H. Kromhout. 2005. "Dermal exposure to cyclophosphamide in hospitals during preparation, nursing and cleaning activities." Int Arch Occup Environ Health 78(5):403­412. ­ Link to external article Sessink, P. J. and R. P. Bos. 1999. "Drugs hazardous to healthcare workers. Evaluation of methods for monitoring occupational exposure to cytostatic drugs." Drug Saf 20(4):347­359. ­ Link to external article Fransman, W., S. Peelen, S. Hilhorst, et al. 2007. "A pooled analysis to study trends in exposure to antineoplastic drugs among nurses." Ann Occup Hyg 51(3):231­239. ­ Link to external article Cass, Y. and C. F. Musgrave. 1992. "Guidelines for the safe handling of excreta contaminated by cytotoxic agents." Am J.Hosp.Pharm. 49(8):1957­1958. deWerk Neal, A., R. A. Wadden and W. L. Chiou. 1983. "Exposure of hospital workers to airborne antineoplastic agents." Am J Hosp Pharm 40(4):597­601. Falck, K., P. Grohn, M. Sorsa, et al. 1979. "Mutagenicity in urine of nurses handling cytostatic drugs." Lancet 1
(8128):1250­1251. Cloak, M. M., T. H. Connor, K. R. Stevens, et al. 1985. "Occupational exposure of nursing personnel to antineoplastic agents." Oncol Nurs.Forum. 12(5):33­39. Page 12 of 13
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Selevan, S. G., M. L. Lindbohm, R. W. Hornung, et al. 1985. "A study of occupational exposure to antineoplastic drugs and fetal loss in nurses." N Engl J Med 313(19):1173­1178. ­ Link to external article Halsen, G. and Kramer, l. 2011 Assessing the risk to health care staff from long­term exposure to anticancer drugs­the case of monoclonal antibodies. J Oncol Pharm Pract. 2011 Mar;17(1):68­80. Epub 2010 Jul 28. ­ Link to external article Disclaimer: This document reflects what is currently regarded as safe practice. While every effort has been made to ensure the accuracy of the contents at the time of publication, the Cancer Institute, NSW does not accept any liability, with respect to loss, damage, injury or expense arising from any such errors or omission in the contents of this work. Any reference throughout the document to specific pharmaceuticals and/or medical products as examples does not imply endorsement of any of these products. The currency of this information is guaranteed only up until the date of printing, for any updates please check www.eviq.org.au ­ 03 Apr 2012 Page 13 of 13