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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 Subscription Rates: 1 Year - $79 / 2 Years - $145 3 Years - $199 ©2004, Quality America® , Inc. All rights reserved. No part of this publication may be reproduced, stored in any retrieval system, or transmitted in any form or by any means—electronic, mechanical, photocopying, recording or otherwise—without the prior written permission of the publisher, Quality America®, Inc. MOVED? Don’t miss a single issue of Quality America’s OSHA Watch! Be sure to let us know if your practice moves or you have an address change.