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OSHA Watch
March / April 2004
Volume 6, No. 2
Revamp Your Sample Med System
How to give your system an overhaul
anding a
FOCUS These are very possible scenarios
that could occur with sample
Medication
patient Zyrtec
Safety
medications that aren’t properly
instead of
managed in your practice.
Zantac? Giving the wrong
dosage? Reaching for a medication
Representatives of drug manufacturers typically provide sample
and learning that it’s out of stock,
medications at no cost, and this
expired, or hasn’t been stored at the
represents a valuable service to those
proper temperature? Wondering
who need to begin a regimen of treatwhere a particular controlled
ment immediately, or to those who
medication went when there were
can ill-afford high-cost prescriptions.
several bottles in stock yesterday?
Although it is a well-intentioned
Wondering which patients received
service to patients, headlines across
medications that were subsequently
the country continue to barrage us
recalled by the manufacturer?
H
FOCUS
Medication Look-Alike
Sound-Alike . . . . . . . . . . . . . . . . . 3
Substance
Abuse in Your
Workplace?
Reducing Prescription Drug
Errors . . . . . . . . . . . . . . . . . . 4
A watchful eye helps
Working Safely with Mercury. . . 6
D
Medication
Safety
Inside . . .
No Easy Answer for Medication
Disposal . . . . . . . . . . . . . . . . . . . . . . . . . 11
Plus . . . Online Training . . .
Buy One, Get One Free Special!
Coming Next Issue:
• TB Regulations Clarification
• OSHA Training Requirements
ecreased job performance.
Unusual clumsiness. Extreme
mood fluctuations. Violent
reactions when things go wrong.
Frequently irritated by coworkers.
Frequent illness. Absenteeism.
Increased accidents. Antisocial
behavior. Do you have someone who
fits this picture at your workplace?
with stories of the approximately
7,000 patients who die per year after
receiving the wrong medication or
the wrong dosage. Granted, these are
usually acutely ill hospitalized
patients, but medication errors also
occur in outpatient settings and can
have devastating consequences.This
issue of OSHA Watch provides
practical suggestions for instituting a
system to organize, manage and track
medications in your workplace. We
also look at safety during the
prescription writing process. Finally,
we discuss the best ways to dispose of
expired medications.
Medication safety isn’t technically an
OSHA issue, but it’s the subject of
several inquiries per month from
—See Sample Med System, page 2
just got up on the wrong side of the
bed. Maybe that person is just going
through a tough personal situation.
Or is it a substance abuse problem?
If you think it can’t happen where
you work, think again. Approximately
10% of the U.S. population has a drug
or alcohol addiction. The healthcare
environment often
feeds the problem
by providing access
not only to OTC drugs, but also to
prescription and controlled
substances. Drugs packaged in small,
convenient samples, left lying on the
counter by drug reps are a great
temptation to an employee prone to
substance abuse.
Maybe the person who comes to mind
Quality America: We Make Compliance Easy! 1-800-946-9956
—See Substance Abuse?, page 12
Page 2
Sample Med System
—from page 1
OSHA Watch March / April 2004
must to avoid inadvertently picking
up the wrong one. Frequently used
methods to store meds are:
alphabetical, by disease class category
(headache, ulcer, diabetes, etc.), or by
medications that are on your
formulary. Think twice about
accepting controlled substances
(Schedule II, III, IV, and V) as
samples. Do not allow pharma-
OSHA Watch readers. So we
at accreditation
FOCUS looked
agency
Medication
Safety
requirements Box A
Receiving Sample Medication Log
and spoke to
several OSHA Watch
Date/
Drug Rep Name Drug Name Expiration Quantity Quantity Recalled
Person Receiving
Phone #
Lot #
Date
Received In Stock
Date
subscribers about how
medications are managed
in their facilities. From
these recommendations, we selected
ceutical reps to deliver sample
type and brand name. A family
the best suggestions for our readers.
medications to you by mail or leave
practice in West Virginia told us that
them unattended in your facility.
their pharmaceutical reps help them
Storing Sample Medications
keep their sample meds organized.
A written policy explaining how
To minimize improper use or theft,
drugs are received, stored, disposed
simply store sample medications
Treatment of Sample
of, and distributed to patients is an
Medications
where patients and unauthorized
employees cannot have access to
Refer to the package insert for special important part of the tracking
storage considerations such process.
as temperature, light, mois- Note: Readers who have Quality America’s
ture, ventilation, and segre- OSHA Safety Program Manual will find
gation. If drugs and vacsuch a policy on page 7-10.
cines require refrigeration,
A suggested Receiving Sample
monitor and document the
Medication Log (See Box A) serves as
refrigerator temperature
a record of sample meds acquired by
daily. A drug that is impropyour facility as well as a reference in
erly stored may lose its
the event of a recall. This type of
effectiveness and potentially
record keeps track of who dropped
harm a patient.
medications off in your facility, who
received them and placed them into
Tracking Sample
Medications
inventory, quantity received, and
expiration date.
Track sample medications to avoid
them. The practices we spoke with
potentially
fatal
mistakes
during
the
use locked cabinets, drawers, or even
A suggested Dispensing Sample
processes of storing, dispensing and
refrigerators—all in a restricted
Medication Log (See Box B) serves as
administering. A tracking system will
laboratory area.
a record of dispensing, receiving,
also prevent employees from
name of drug, dosage and quantity
Keep narcotics and controlled
pocketing drugs for personal or
given. It is advisable to have the
substances in locked areas with DEA
family use.
ordering forms. Michiko Martin of
—See Sample Med System, page 3
Consider accepting only sample
Family Medical Center in Smithville,
TN stated, “There are two locks on
Box B
Dispensing Sample Medication Log
our controlled substance lock box
and it requires two nurses with difDrug Name
Signature of
Signature of
ferent keys to access the medication.”
Patient Name
Date
Organizing Sample Medications
Organizing sample medications is a
Phone #
Strength/Qty
Dispensed
www.quality-america.com
Person
Dispensing
Patient
Receiving/Qty.
OSHA Watch March / April 2004
MEDICATIONS
LookAlike
SoundAlike
Allegra Viagra
Hyzaar Cozaar
Benadryl Benylin
Imipramine Desipramine
Celexa Celebrex
Inderal Isordil
Cipro Ceftin
Lamisil Lomotil
Codeine Iodine
Lanoxin Lasix
Codeine Lodine
Lorazepam Clonazepam
Demerol Desyrel
Nitroderm Nicoderm
Erythromycin Azithromycin
Paxil Plavix
Flomax Volmax
Plendil Isordil
Flomax Fosamax
Prednisone Primidone
Folic Acid Folinic Acid
Prilosec Prozac
Granulex Regranex
Xanax Zantac
Haldol Stadol
Zoloft Zocor
Heparin Hespan
Zyrtec Zantac
Hydrocortisone Hydrocodone
Source: US Pharmacopeial Convention
Page 3
Sample Med System
—from page 2
signature of both the employee
dispensing and the patient receiving
the sample medications.
For convenience, consider keeping
these logs on a clipboard in the
medication storage area.
Dispensing Sample Medications
Permit only licensed healthcare
providers to dispense sample
medications. In some states, only
physicians, pharmacists, physician
assistants, or nurse practitioners may
dispense sample medications.
Do not divert samples for use by
employees, unless prescribed by their
physician as part of treatment. In that
case, follow protocol used for
dispensing sample medications to
patients.
In most small ambulatory medical
settings, samples are dispensed
without computer screening for drug
interactions, duplicated therapy,
allergies or contraindications.
Medication errors may occur due to
interruptions, lack of communication,
or environmental stress such as
lighting, heat, noise.
Use the Dispensing Sample
Medication Log (Box B) as the
primary record-keeping log. Also
consider altering it to serve as a
“prescription pad” for dispensing
sample medications. If this pad is
more convenient for your practice,
post a copy in the patient’s medical
records, and a second copy in a binder
maintained in the locked sample
medication area. If desired, a third
copy could be given to the patient.
Should you choose to reproduce the
pad in quantity, make the pages a
different color from your regular
prescription pads.
www.quality-america.com
A sample medication given without
appropriate documentation is a safety
risk. Indicate on the patient’s chart
the samples given. Document the
drug name, strength, dosage, form,
and frequency of administration.
Remember to apply a label with
specific instructions on the samples
or give patients written instructions
for taking samples.
Errors also occur in the sampledispensing process with sound-alike
and look-alike drug names. The table
OSHA on
Managing
Medication
OSHA doesn’t take a firm stand
on how to manage medication,
since patient safety isn’t OSHA’s
concern. But employee health
is OSHA’s concern and drugs
are considered hazardous
materials and thus fall under
the Hazard Communication
Standard (29 CFR 1910.1200).
to the left shows some common drugs
that can be mistaken for one another.
Inventory Sample Medications
Take inventory a minimum of once a
month. Subtract outdated
medications from the “Quantity in
Stock” column on the Receiving
Sample Medication Log.
Drug Recalls
Drug recalls occur with increasing
regularity, making clear the need for a
sample medication tracking
mechanism. Notify patients who were
given the recalled drug. This process
could be lengthy and costly if a
—See Sample Med System, page 10
OSHA Watch March / April 2004
Page 4
More on
Reducing
Prescription
Drug Errors
P
atients getting the wrong
medicine or the wrong dose of a
medicine account for a high
percentage of medical errors.
In the May/June 2003 OSHA Watch
we suggested several ways to
minimize mistakes with both written
and verbal drug orders, such as
Abbreviation = True Meaning
writing the purpose of the medication
(e.g., indication for use) on the
prescription. We also published a list
of problem-prone abbreviations
frequently seen on prescription pads
and patient charts. In early 2004, the
Joint Commission on Accreditation of
Health Care (JCAHO), as part of their
Patient Safety Goals, updated the list
of “dangerous” abbreviations–ones
that are most likely to cause a
prescription/medication error.
Abbreviations previously listed in
OSHA Watch (May/June 2003) are
not repeated in the table below.
For a complete list of error-prone
abbreviations such as the ones below,
go to: http://www.ismp.org/PDF/
ISMPAbbreviations.pdf?itemID=21576
The lion’s share of prescription drug
errors are due to illegible handwriting. The problem is serious
enough to cause the Institute for Safe
Medication Practices (ISMP) to call
for eliminating handwritten
prescriptions. Physicians who are
notorious for poor handwriting might
be convinced to print or go electronic
by seeing that the time saved due to
scrawling prescriptions is lost in
subsequent telephone calls from
pharmacists and patients.
Misinterpretation (Bad Handwriting/Typo)
Correction
cc = cubic centimeters
Mistaken as “u” (units)
Use “mL”
IJ = Injection
Mistaken as “IV” or “intrajugular”
Use “injection”
IN = Intranasal
Mistaken as “IM” or “IV”
Use “intranasal” or “NAS”
IU = International Unit
Mistaken as IV (intravenous) or 10 (ten)
Use “units”
q.d. or QD = everyday
Mistaken as q.i.d., especially if the period after the “q”
or the tail of the “q” is misunderstood as an “i”
Use “daily”
qhs = Nightly at bedtime
Mistaken as “qhr” or every hour
Use “nightly”
q.o.d. or QOD = Every other day
Mistaken as “q.d.” (daily) or “q.i.d.” (four times daily) if
the “o” is poorly written
Use “every other day”
q1d = daily
Mistaken as q.i.d. (four times daily)
Use “daily”
t/d = one daily
Mistaken as “tid”
Use “1 daily”
U or u = Unit
Mistaken as the number 0 or 4, causing a 10-fold overdose or
greater (e.g., 4U seen as “40” or 4u seen as “44”); mistaken as “cc” so
dose given in volume instead of units (e.g., 4u seen as 4cc)
Use “unit”
Dose Designations
Trailing zero after decimal point
(e.g., 1.0 mg) = 1 mg
Mistaken as 10 mg if the decimal point is not seen
Don’t use trailing zeros for
doses expressed in whole numbers
No leading zero before a decimal dose
(e.g., .5mg) = 0.5 mg
Mistaken as 5 mg if the decimal point is not seen
Use zero before a decimal point
when the dose is less
than a whole unit
Mistaken as hydrochlorothiazide
Use complete drug name
Drug Names
HCT = hydrocortisone
MgSO4 = magnesium sulfate
MS or MSO4 = morphine sulfate
Mistaken as morphine sulfate
Use complete drug name
Mistaken as magnesium sulfate
Use complete drug name
Mistaken as sodium nitroprusside infusion
Use complete drug name
Stemmed Drugs
“Nitro” drip = nitroglycerin infusion
Source: JCAHO 2004 Patient Safety Goals
www.quality-america.com
Page 5
OSHA Watch March / April 2004
Medication List
*Medicine Name
and Dosage
Name of
Prescribing Doctor
When Taken
Why Medicine Is Taken
Side Effects of Medicine
*Include Prescriptions, OTC Medications, Herbal Remedies and Vitamins
Avoiding Multiple Drug
Interactions
Barcodes Have
Earned Their Stripes
Another error that can occur is prescribing a medication that conflicts
with another drug that the patient is
taking. To minimize this possibility,
either ask patients to bring in all of
their medications, or ask them to list
the medications they are taking. A
sample Medication List that can be
used for this purpose is shown above.
Last February, the FDA mandated barcode
labels for prescription drugs to help reduce
the number of medication errors. Healthcare
workers scan a barcode (just like the kind
used at the grocery store) on a drug to be
dispensed in order to match the barcode on
a patient’s wristband or chart. Drug
companies are now putting barcodes on
medications sold to hospitals. This new
development seems to confirm that barcodes
will continue to play an important role in
your workplace in the next few years.
Sources: JCAHO Patient Safety Goals
http://www.jcaho.org/ accredited+organizations/patient+safety/index.htm; Family
Practice Management, July/August 2002.
Prescription Writing to Maximize Patient
Safety. www.aafp.org/fpm
Institute for Safe Medication Practices
http://www.ismp.org/PDF/ISMPAbbreviation
s.pdf?itemID=21576
ANSWER TO LAST MONTH’S
QUESTION OF THE MONTH
Question
?
of the Month
Can vaccines and
food be stored in
the same
refrigerator?
OSHA’s Bloodborne Pathogen
Standard prohibits storing food
and drinks in a refrigerator that
contains serum-based vaccines
or blood. It is also remotely possible that non-serum
based vaccines could contaminate employee food.
Vaccine storage conditions must be strictly monitored,
as vaccines are prone to lose their potency if
temperatures are not accurately maintained. Most
“break room” refrigerators are opened and closed
frequently and are not equipped with monitoring
systems to maintain a consistent temperature. Have a
special refrigerator for vaccine storage and monitor the
temperature daily.
www.quality-america.com
Page 6
OSHA Watch March / April 2004
entire carpet. Contact your local EPA
office and biohazardous waste hauler
for help with mercury disposal and
handling large spills.
Working Safely with…
Mercury
M
ercury is found throughout
the healthcare industry in
items ranging from
thermometers and switches to
sphygmomanometers and valves, but
this toxic liquid metal will soon be
phased out for occupational health
and environmental reasons.
The American Academy of Family
Practice and the American Hospital
Association have committed to
replace devices containing mercury
with mercury-free alternatives by
2005. But there are no federal laws
prohibiting mercury in the work
place at present. Certain states ban
mercury, or at least prevent sales of
products containing mercury.
Why all the fuss? Weren’t we all
fascinated with those little silver blobs
of mercury as children? In recent
years, American consumers have been
cautioned about the dangers of eating
seafood from mercury-contaminated
waters. Chronic exposure to mercury
may result in weakness, fatigue,
States with Mercury
Washington
Oregon
California
Minnesota
Illinois
Indiana
Michigan
Maine
New Hampshire
Connecticut
Massachusetts
Maryland
Rhode Island
anorexia, weight loss, and disturbance
of gastrointestinal function.
When mercury-containing equipment
fails or breaks, healthcare workers
receive many harmful effects. These
include chills, nausea, general
malaise, tightness in the chest, chest
pains, dyspnea, cough, stomatitis,
gingivitis, salivation, and diarrhea.
Handling Mercury Spills
A family practice office in North
Carolina recently experienced a
mercury spill in one of their exam
rooms. A nurse was having trouble
with the wall-mounted blood pressure
gauge, so the staff wheeled an old
gauge that had been stored in a closet
into the exam room. When the bulb
was compressed, all of the mercury
leaked out of the bottom of the unit
onto the carpeted floor!
Unfortunately, there is no fast, cheap,
or easy way to handle a mercury spill,
especially when the floor is carpeted.
Regardless of the type of floor surface,
the first order of business is to
evacuate employees
Restrictions and patients and
close off the room to
prevent further
exposure incidents to
the toxic vapors.
It’s just about
impossible to remove
all of a mercury spill
from a carpet, even
with a spill kit. You
will need to cut out
the contaminated
carpet or replace the
www.quality-america.com
A local hazardous waste removal
company will pick up used mercury
spill kits for a price. Alternatively, the
Environmental Protection Agency
(EPA) may charge several thousand
dollars to remove mercury from your
premises, so we recommend storing
the safely confined mercury in the
screw-capped jar in a safe location
labeled “Mercury for Recycling”. If
your state eventually bans mercury,
they will likely provide free mercury
recycling for a short period after the
regulation is passed.
Mercury Spill Clean Up
1. Evacuate personnel and
restrict access to the room
where the spill occurred.
2. Put on a mask before
beginning cleanup.
3. DO NOT VACUUM!
Use one of these methods to
clean up the mercury bead:
• A commercial mercury
spill kit
or
• Roll the bead onto a
sheet of paper
or
• Suck up the bead with
eyedropper.
4. Dispose according to the spill
kit instructions or place in a
screw capped glass jar.
5. Use a fan to speed ventilation
and open a window (if possible). Otherwise, close off the
room for at least one hour.
Page 7
OSHA Watch March / April 2004
ASK THE EXPERT
Storing Vaccines, Discarding Flu Vials, Lab Coat Length
Helping
People
with Their
Meds
email them to us at qualityamerica
@charter.net or call us at 800-9469956.
Q: I have just Q: We’ve had a rough flu season this
reviewed the
Discarding Flu Vials
May/June
2003 issue of
OSHA Watch
regarding
medical
errors. I was
Dr. Sheila Dunn
wondering if
you or any
other readers have input on how to
teach an illiterate patient to take
their pills. Some of our patients have
multiple meds and are unable to set
up their med box. Any advice would
be greatly appreciated.
A:
One idea is to have
the patient bring their
med box in with the
days labeled
(M,T,W,Th,F,S,Su) for a
whole month. Have the
nurse fill up each day
with the correct
number of each pill and
send it back home with
the patient. Then, the
patient need only
remember that M =
Monday, T = Tuesday,
and so on, and to take
the pills for that day.
You could also ask the
pharmacist to do this
for these patients. If
anyone has other
suggestions that have
worked for you, please
year. Now I have several dozen
empty flu vaccine vials. How do I get
rid of them?
A: There is no live virus or human
serum in the flu vaccine, and since it
is transmitted via airborne/respiratory mechanisms, it does not
fall under the Bloodborne Pathogens
Standard. Intact vials are not
considered a sharps hazard, and
therefore do not need to be placed
into sharps containers. As far as
OSHA is concerned, intact, empty
vials can be thrown
out with the regular trash. Better
yet, recycle them!
Storing Vaccines
Q: At what temperature do I need
to store vaccines?
A: The US Centers
for Disease Control
and Prevention
(CDC) recommend
storing most vaccines at 2-8° C and
monitoring the
refrigerator
temperature daily.
Since storing
vaccines at
temperatures that
are too high or too
low can irreversibly
www.quality-america.com
reduce their potency, do not expose
refrigerated vaccines to freezing
temperatures. Only live, attenuated
influenza vaccines (e.g., Flu Mist) and
the varicella vaccine must be frozen.
Flu Mist must be stored below –15°C.
It is difficult to achieve this temperature in a regular frost-free freezer,
since the temperature often cycles
above 15°C in the freeze-thaw cycle.
Flu Mist may be thawed in a refrigerator and stored at 2- 8°C for <24 hours
before use, but it shouldn’t be
refrozen after thawing. Additional
information is available at Wyeth
Product Quality (800-411-0086).
To monitor temperatures of
refrigerators and freezers where
vaccines are stored, use a thermometer
immersed in ethylene glycol
(antifreeze). Ideally, a min-max
thermometer with a continuous chart
recorder could also be used.
CDC also recommends:
• Have written policies for
vaccine storage.
• Train personnel on these policies.
• Log temperatures for vaccine
storage units.
• Address any out-of-range
temperature problems by
contacting the vaccine
manufacturer or by calling
your local health department.
• Have a back-up storage plan in
the event of power outages or
equipment failure.
Source: CDC Morbidity and Mortality
Weekly Report 10/24/03
OSHA Watch March / April 2004
Page 8
When to Wear Gloves
Q: Are we required to wear gloves
while starting an IV? We have an
ongoing debate regarding this topic.
bench to change reagents, etc., so my
advice is to provide full-length lab
coats to everyone.
A: Absolutely! Starting an IV is a
Food and Drink in
Administrative Areas
Q: Is it an OSHA violation to allow
eating or drinking in the administrative areas of a healthcare facility?
vascular access procedure, and OSHA’s
Bloodborne Pathogens Standard (29
CFR 1910.1030) requires that gloves
be worn in any situation where hands
could come into contact with blood or
other potentially infectious materials.
Refer to Quality America’s OSHA
Safety Program Manual behind Tab 5,
for written policies concerning wearing gloves.
Lab Coat Length
Q: Could you please clarify OSHA’s
PPE requirements regarding lab
coats? I know that they must be
impervious to liquid, long-sleeved
with closed cuffs, but what about
length? I have previously understood
that they need to be long (knee
length), but I have some
employees who insist that since
most of the work is done at
counter-top level, a hip-length
coat is acceptable. Our lab techs
draw blood, run tests, change
reagents, sometimes assist in
the chemo room starting lines
and perform therapeutic
phlebotomies. The chemo RNs
do all this plus administer
chemotherapy agents. Is there a
definite length limit and if so,
what is it? (Cancer Care Center
in Missouri)
A: Since OSHA is concerned only
situation, then a hip-length lab coat
will suffice, but if they stand up and
move elsewhere to perform other
tasks that could expose them to a
splash/spray, then the lab coat must
be full length (to the knee). It sounds
like your employees multi-task and
do, in fact, move away from the
with the health and safety of
employees, the issue is whether or not
employee’s food/drink could become
contaminated with either infectious
materials (blood, body fluids) or
hazardous chemicals. If there is a
remote possibility of this occurring,
such as lab specimens passing
through the area, then food and drink
must be prohibited by the employer.
In most medical settings, OSHA
compliance is not the only concern.
Insurance company auditors or
accreditation agency inspectors
often cite facilities for having
food or drink in non-clinical
areas. And aesthetic issues can be
a factor. For instance, front office
personnel who are eating and
drinking do not appear
professional, the sound of eating
or odor of food can be offensive,
and spills happen easily around
computer keyboards or patient
records.
Include employees’ input when
deciding on an office food/drink
policy. Are employees who wish
to eat/drink at their workstation
provided with adequate break
times? Then, establish your
policies based on a combination
of OSHA, infection control, usual
and customary behavior for
medical settings, and common
sense. Once your policies are
established, communicate them
to staff and require compliance
by everyone...no exceptions!
A: You’re right about lab coats
as it pertains to impermeability,
cuffs, etc. OSHA doesn’t specify a
length though, only stating that
the employee’s street clothes and
skin must be protected from
splashing/spraying of potentially
infectious materials and
hazardous chemicals. So, the
bottom line is: if an employee is
working ONLY in a bench top
www.quality-america.com
Page 9
OSHA Watch March / April 2004
IN THE NEWS
Preventing Medical
Gas Mistakes
In the past five years, 7 patients have
died and 15 others have been injured
as a result of healthcare providers
mistakenly connecting their oxygen
line to a non-oxygen source fitting.
To avoid such a catastrophe in your
workplace, a new FDA Alert advises
how to store and handle medical
gases:
• Avoid storing medical-grade products with industrial-grade products.
• Carefully examine all medical gas
labels and recognize when a supplier
uses 360-degree, wraparound labels
to designate medical oxygen. Check
that all tanks connected to oxygen
bear that same label.
• Check that medical gas tanks are
securely connected to the system. If
in doubt, ask your supplier to check
the connection prior to releasing the
gas into the system.
• Contact your supplier if a fitting
doesn’t connect securely. Under no
circumstances should an employee
tamper with a problem fitting or
proceed with releasing the gas into
the system.
Source: Food and Drug Administration
www.fda.gov
Bizarre Bloodborne Pathogen
Mooooves In!
It’s likely that the British patient who
died of the human form of mad cow
disease [a variant of Creutzfeldt-Jakob
disease (vCJD)] was infected by a
tainted blood transfusion, bolstering
fears that the disease can be spread
through the bloodborne route. Up
until now, scientists have believed
Human vCJD Cases
(12/1/03)
United Kingdom...................143
France.......................................6
Canada ......................................1
Ireland ......................................1
Italy ...........................................1
US............................................*1
Total .................................153
*Patient lived in the UK before
moving to the US
that this brain-destroying disease
could only transmitted by eating
meat from cattle infected with bovine
spongiform encephalopathy (BSE).
Now that vCJD has emerged in
Washington state, there is the
possibility that humans could
become infected and unknowingly
contaminate our blood supply…or be
the source patient for a needlestick or
other sharps injury to a healthcare
worker.
There is no treatment or test for
diagnosing vCJD in humans, which
begins with profound psychiatric or
behavioral changes, and continues for
a year or longer before death.
Source: CDC Fact Sheet: New Variant
Creutzfeldt-Jakob Disease
http://www.cdc.gov/ncidod/diseases/cjd
/cjd_fact_sheet.htm
vCJD Symptoms
• Neurologic abnormalities,
(incoordination, dementia,
sudden muscle contractions)
• Illness over 6 months
• Diffusely abnormal nondiagnostic EEG
www.quality-america.com
Medication Error Takes
Youngster’s Life
A 2-year old cancer patient at Johns
Hopkins Children’s Center died after
receiving an IV feeding solution
containing 4 to 5 times the normal
dose of potassium. Communication
errors between the hospital and the
pharmacy that manually formulated
the parenteral nutrition were likely to
blame, but the child’s distraught
parents implicated a “cascade of
failures” in a system without enough
safeguards.
Source: Associated Press. Friday December
19, 2003.
Ricin Surfaces in U.S. Capitol
A deadly nerve agent similar to the
sarin gas that killed 12 and injured
5,134 people in the 1995 Tokyo subway disaster was discovered in the
Dirksen Senate Office Building, office
of Senate Majority Leader Bill Frist in
early February. After a week’s worth
of cleanup, officials declared the
building safe and reopened the offices.
No one has become ill although
dozens of Capitol Hill employees
underwent decontamination.
Ricin is derived from the castor bean
plant and is 1500 times more deadly
than cyanide when inhaled or
ingested. About 6 hours after exposure to ricin, flu-like symptoms
including fever, cough, shortness of
breath and chest tightness are likely
to appear. Multiple organ failure and
death can occur within 36 to 72
hours. There is no antidote for ricin
exposure.
Ricin could be perilous for healthcare
workers too; 10 percent of the 1,364
emergency personnel who treated
OSHA Watch March / April 2004
sarin-exposed patients in Tokyo
required medical treatment for
dimmed vision, rhinorrhea, chest
tightness and cough.
Federal authorities are investigating
whether this ricin attack is connected
to a letter containing the same deadly
poison that was sent to the White
House in November.
Sources: www.cdc.gov and USAToday.com
A Taste of Their Own Medicine
A little known loophole in the
Bloodborne Pathogens Standard
(20CFR 1910.1030) exempts
employees in certain states from
OSHA regulations. Federal, state,
county, and municipally-owned
healthcare facilities in 13 states without “state” OSHA plans (Alabama,
Arkansas, Colorado, Florida, Idaho,
Illinois, Louisiana, Mississippi,
Montana, North Dakota, Nebraska,
South Dakota and Wisconsin) have
Page 10
never been subject to OSHA
regulations! Believe it or not,
government employees in these states
are not required to practice universal
precautions, use safety sharps, or even
wear gloves, although most
voluntarily abide by OSHA regulations
for the well-being of their employees.
TB Vaccine in the Works
The first human TB vaccine is being
developed to help prevent the greatest
single infectious cause of death in the
world. TB infects 8 million people and
kills 2 million people each year. About
one third of the world’s population
carries TB.
The 2003 Medicare Modernization Act
will soon close this loophole by
requiring all healthcare facilities
across the nation to comply with
every provision of the Bloodborne
Pathogens Standard. Starting July 1,
2004, all government employees will
be required to wear gloves, not re-use
tube holders, use sharps containers,
and not sip on diet colas in the blood
collection area! There will be a sixmonth grace period before citations
and fines are issued.
TB is currently treated by a regimen
of antibiotics taken for six to nine
months, but strains of TB are
resistant to these antibiotics. BCG,
the only currently-available vaccine,
was developed over 70 years ago and
is no longer used in the US because it
doesn’t work consistently and wears
off after time.
Source: Sec. 947 of the Medicare
Prescription Drug, Improvement and
Modernization Act of 2003, which amends
Title XIII of the Social Security Act.
Comic Relief
Seattle biotechnology company
Corixa Corp. and the pharmaceutical
giant GlaxoSmithKline are testing the
new DNA-based vaccine for safety. It
could take eight to ten years before
the vaccine reaches the market.
Sample Med System
—from page 3
medication dispensing system is not
used. Imagine having to search patient
records for the entire period prior to
the medication recall!
If a drug is recalled, document the
date of recall notification and the
quantity sent back to company. Also
record the method by which recalled
drugs were shipped back to their
manufacturer by traceable means (i.e.,
UPS or FedEx) along with the name
and signature of sender.
Human error is unavoidable. But, by
implementing this type of management system, you will decrease the
risk of error and increase safety and
security in providing sample
medications to your patients.
www.quality-america.com
Page 11
OSHA Watch March / April 2004
No Easy
Answer for
Medication
Disposal
Expired or unwanted drugs are
disposed of in a variety of ways by
medical practices. We interviewed a
variety of subscribers, from an
OB/GYN practice in Minnesota to a
family practice in South Carolina.
Their range of methods used to
dispose of meds were:
• Include with infectious waste
min red biohazardous bags
• Throw in the dumpster
• Flush down the toilet
• Return to the sales rep
• Give to over-seas missions
Although there seems to be no
perfect or easy way to get rid of
unwanted meds, consider the pros
and cons for each of the following
when deciding how your practice will
handle this issue.
Flushing Meds?
In a word, ‘DON’T! Flushing drugs
down the toilet gets rid of them for
you and prevents misuse by potential
abusers, but everything that goes
down your drain ends up at the
municipal wastewater treatment plant
(WWTP) before it is eventually discharged into a nearby stream, river,
lake, or ground water. WWTPs rely on
microorganisms to digest incoming
waste. Prescription and OTC drugs
(particularly antibiotics) could impair
those microorganisms, preventing
the WWTP from effectively breaking
down waste.
Drugs in the sewage system could also
affect aquatic or terrestrial ecosystems.
• Double-enclose drugs in a bag
or wrapping so that they are
not easily identifiable.
Out with the Biohazardous
Waste Hauler?
Throwing out your expired meds in
red biohazard waste bags or sharps
containers will prevent misuse, but
many biohazardous waste haulers
refuse to accept them.
Many drugs are not captured in the
treatment process and are released
into the environment. Over 80% of the
surface water in North America has
traces of prescription and OTC drugs
in it. About 40% of surface water has
traces of antibiotics, which facilitates
the development of antibiotic resistant
organisms.
Throw in the Regular Trash?
This disposal option poses real
problems with unintended use by
those with access to trash cans and
dumpsters. Controlled substances
thrown in the trash will be very
attractive to people seeking free meds
or to addicts looking for a fix. To
prevent misuse of drugs disposed of
in the trash:
• Add a small amount of water to
solid drugs before disposal.
• Add a small amount of
absorbent material (such as
sawdust, flour, or kitty litter)
to liquid drugs.
Question
?
of the Month
Some biohazardous waste haulers do
provide chemical and drug waste disposal. A special box or container may
be used. This definitely adds to your
cost of waste removal, but is
absolutely necessary for very
hazardous medications, such as
chemotherapy drugs, which must be
placed in special yellow waste
containers. Contact your biohazardous waste hauler for specific pricing options.
Some “hazardous” drugs must be
disposed of in accordance with EPA
and DOT hazardous waste guidelines.
Refer to both the MSDS and the
package insert for guidance on safe
storage and disposal.
Independent hazardous waste transporters can also dispose of drug waste,
but the cost may be very expensive for
such a special pick-up. If you go this
route, check with the transporter to
see if they are charging you per
weight or per pick-up. Limit the
—See Medication Disposal, page 12
What types of OSHA training
records are necessary for
healthcare employees?
Find out in the next edition of
Quality America’s
OSHA Watch.
www.quality-america.com
OSHA Watch March / April 2004
Page 12
Medication Disposal
Substance abuse?
—from page 11
—from page 1
SAMPLE EXPIRED MEDICATION ACCEPTANCE AGREEMENT
Date: ______________________
Practice Information
Name of Practice or Facility: _______________________________________________
Name of Practice Representative: ___________________________________________
Pharmaceutical Company Information
Name of Company: ______________________________________________________
Name of Sales Rep:______________________________________________________
1.
Medication Name
# Received
2.
3.
4.
5.
In accordance with the OSHA Hazard Communication Standard (29 CFR 1910.1200), the
proper disposal of expired drugs and medications eliminates the potential of exposure to
hazardous materials. In signing this agreement, the pharmaceutical company listed above is
taking an active role in ensuring the health and safety of employees and patients at this
facility.
The pharmaceutical company listed above agrees to pick-up any leftover and/or expired
medications from this medical facility. The pharmaceutical company listed above will take full
responsibility and ownership for such medications once they leave this facility. Above listed
medications shall be disposed of in accordance with federal, state, and local environmental,
transportation, and safety regulations.
_________________________________________
Signature of Pharmaceutical Sales Rep.
Substance abusers in the medical
setting put everyone at risk. They
contribute to missed work time,
injuries, worker’s compensation
claims, overtime pay, and sick leave,
increasing operational costs. Morale
suffers when employees are injured,
equipment is damaged, or coworkers
have to pick up the slack to cover for
sluggish, late or absent workers.
______________
Date
If you need a copy of this form, it can be downloaded from:
http://www.osha-compliance.com/osha-resources/index.htm
number of pick-ups per year to cut
cost. Label expired drugs as “expired”
and keep them in a separate location
with restricted access until “pickup”.
Return to the Vendor?
The best way to dispose of unused or
expired drugs is to give them back to
the pharmaceutical representative.
Have a written agreement to arrange
for pick-up of unused or expired
meds. If you are interested in such
an agreement, please visit http://
www.osha-compliance.com/osharesources/ index.htm (OSHA Watch
Resource Center) to download a
Sample Expired Medication
Acceptance Agreement.
Donate to Missions?
Although it’s illegal to distribute
expired meds in the US, many third
world countries don’t have access to
quality medical treatment or
medications. To help them, various
groups collect and donate expired
meds to overseas missions. If you do
donate your drugs to missions, be
sure that you deal with a licensed
and reputable healthcare practitioner
and that they have the means to get
the medication to those who actually
need it.
Check Your Substance
Abuse Policy
Does it:
• Define prohibited substances?
• Prohibit manufacturing, possession,
or inappropriate distribution and sale
of drugs to patients, the public, or
other employees?
Coming
Next Issue
Look for the
May/June 2004
edition of OSHA Watch
with all your favorite
features, including . . .
Ask the Expert
In the News
Plus . . . .
TB Regulation Clarification
OSHA Training
Requirements
and much more!
OSHA Watch
Published bi-monthly
by
• Specify discipline for a violation(s)
(e.g., written warning, suspension,
termination)?
• Require prosecution for illegal
activity on site?
• Offer non-punitive help for those
who request it?
• Require that substance abusers
undergo and successfully complete a
rehabilitation or treatment/
counseling program, or both?
Keep your workplace from having a
drug problem by:
• Establishing a company substance
abuse policy.
• Safely storing, organizing,
tracking, dispensing and disposing
of all drugs (See Revamp Your
Sample Med System).
• If there is reason to suspect substance abuse because of accidents,
irregular behavior or appearance,
consider random drug testing.
www.quality-america.com
Dr. Sheila Dunn, President & CEO
PO Box 8787 • Asheville, NC 28814
1-800-946-9956
www.quality-america.com
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