The new standards from the US Pharmacopeoal (USP) Convention address the importance of informing healthcare workers (HCWs) about the adverse reproductive outcomes from exposure hazardous drugs (HDs).

 The standard appears in the USP Chapter <800> section on Hazard Communication and states that all personnel who are capable of reproduction must acknowledge in writing that they have received information and that they understand the risks associated with HD handling.

This is an important step forward in safety for HD handlers, which has implications for every organization where HDs are present, as implementation may require several changes in policy and practice.

Many drugs are hazardous to reproductive function in women, men, or both, affecting their ability to conceive and bear healthy children. Such effects may occur as a result of changes in ovarian function, sperm production, or hormonal changes. Some drugs have a direct effect on an embryo or fetus, such as antineoplastic agents that damage rapidly proliferating cells in the same way that they destroy cancer cells. Two criteria for drugs to be labeled as hazardous are teratogenicity (structural defects in a fetus) and reproductive toxicity.2 (

HDs are identified as reproductive toxins based on:

Animal or human studies during drug development (eg, Black Box Warnings in prescribing information)

Postmarketing reports of adverse outcomes (eg, thalidomide)

Evidence of reproductive harm from epidemiologic studies (eg, increased miscarriages in Nurses' Health Study II)

Infertility has occurred in patients treated with antineoplastic drugs and has also been reported in nurses from occupational HD exposure. In one study, exposed nurses took longer to conceive than nonexposed nurses.

 In others, infertility occurred up to 1.5 times more frequently in exposed nurses.

Few studies have had sufficient numbers of participants to clearly document birth defects in HD-exposed healthcare workers. One recent study, in which “exposure” was defined as chemotherapy handling, reported an increase in miscarriages, with higher occurrence in exposed nurses during their first pregnancy

The National Institute for Occupational Safety and Health (NIOSH) has compiled a list of drugs that should be handled as hazardous. The NIOSH list is divided into 3 separate tables: (1) Antineoplastic drugs; (2) Non-antineoplastic hazardous drugs; (3) Drugs with primarily reproductive effects. Drugs in table 3 need only be considered harmful “to males or females who are actively trying to conceive, women who are pregnant or may become pregnant, and women who are breastfeeding.”

 Drugs in tables 1 and 2 may have adverse reproductive effects as well as being carcinogens, mutagens, and organ toxins.

HD safe handling precautions are necessary for all personnel because healthcare settings should be safe for everyone. The recommendations from the American Society of Health System Pharmacists, NIOSH, the Occupational Safety and Health Administration, the Oncology Nursing Society (ONS), and USP agree that the use of engineering controls, administrative controls, and personal protective equipment (PPE) will reduce exposure. Evidence suggests, however, that current work practices cannot completely eliminate exposure.

Known spills and environmental contamination are sources of exposure that workers cannot necessarily avoid if they are involved in HD preparation, administration, or handling of contaminated excreta, illustrating the need for other practices that provide additional protection for workers who are vulnerable to reproductive harm because of their life situation.

One recommendation for nurses or other HCWs who are actively trying to conceive, pregnant, or breastfeeding is to refrain from HD handling activities. This is referred to as alternative duty or temporary reassignment and is a “recognized risk management strategy.”

This involves identifying job tasks that do not include HD handling that the HCW can safely perform. In order for such a program to be implemented, all employees must be aware of the risks of exposure around pregnancy, the availability of alternative duty, and the process for requesting such duty.

Information about the risks of HD exposure must be provided as a part of a hazard communication program. Employees may not be aware of the need to avoid HD exposure around pregnancy and should be provided with specific information during initial education and training.

The USP standard for acknowledging receipt of information in writing is a good way to document the initial education. HCWs should be retrained about the risks in annual updates, since their life situation may have changed.

Organizations must develop a policy that addresses alternative duty. Current recommendations from ONS and the American Nurses Association support alternative duty that does include HD handling when an employee requests it.

 Policies should be written instead of implied, so that there is a formal mechanism to protect nurses when making patient care assignments.

The formal process should include who the employee should contact to request alternative duty and how that request is made. HCWs should notify their manager or supervisor when they want to refrain from handling HDs so that appropriate levels of staffing can be provided.

1. US Pharmacopeial Convention Chapter <800>: Hazardous Drugs—Handling in Healthcare Settings. 

2. National Institute for Occupational Safety and Health. NIOSH List of Antineoplastic and Other Hazardous Drugs in Healthcare Settings, 2016. 

https://www.cdc.gov/niosh/topics/antineoplastic/pdf/hazardous-drugs-list_2016-161.pdf

3. Fransman W, Roeleveld N, Peelen S, et al., Nurses with dermal exposure to antineoplastic drugs: reproductive outcomes. 

4. Martin S. Chemotherapy handling and effects among nurses and their offspring (Abstract). 

5. Valanis B, Vollmer W, Labuhn K, Glass A, et al. Occupational exposure to antineoplastic agents and self-reported infertility among nurses and pharmacists. 

6. Lawson CC, Rocheleau CM, Whelan EA, et al. Occupational exposures among nurses and risk of spontaneous abortion. 

7. American Nurses Association. Reproductive Rights of Registered Nurses Handling Hazardous Drugs. 

http://www.nursingworld.org/MainMenuCategories/WorkplaceSafety/Healthy-Work-Environment/reproductive-rights-of-rns-handling-hazardous-drugs.pdf

8. Oncology Nursing Society. Ensuring healthcare worker safety when handling hazardous drugs. 

https://www.ons.org/advocacy-policy/positions/practice/hazardous-drugs

Articles

Nurses may not be aware of the reproductive risks of exposure to hazardous drugs, but the new USP Chapter  requires a formal notification process.


Hazardous Drugs and Reproductive Effects: Understanding the Risks

The use of chemotherapy and other hazardous drugs (HD) is increasing each year. With an estimated 1.68 million individuals in the US diagnosed with cancer in 2016,

 the number of patients who are likely to be treated with chemotherapy is quite high. Add the multiple uses of chemotherapy for nononcology indications and the over 100 nonantineoplastic HDs in common use, and HDs can be present anywhere in healthcare settings

Most oncology nurses are knowledgeable about exposure; however, results from a study of nurses’ use of safe handling precautions for HD handling found that 15% of those nurses did not know that HDs left behind on surfaces can be a source of exposure.

The routes of occupational exposure to HDs are absorption, inhalation, ingestion, and injection (Figure). Initially, inhalation was thought to be the main source of occupational exposure to HDs. Aerosols are generated when drugs are withdrawn from vials, which led to the use of biosafety cabinets (BSCs) in the 1980s. Dermal absorption is a common exposure route and is possible during any HD handling activity. The purpose of personal protective equipment (PPE) is to provide barrier protection from HDs.

Figure. Exposure to Hazardous Drugs in Occupational Settings

			Hand-to-mouth transfer from contaminated items/surfaces

			Release of drug vapor in the environment

Puncture injury with drug-contaminated needles or other sharps

 the presence of cyclophosphamide residue was first identified on surfaces in pharmacies and chemotherapy administration areas. The presence of environmental contamination was recognized as a source of exposure for healthcare workers who might absorb HD residue when touching workplace surfaces.

Residue can be transferred to other items and surfaces, resulting in exposure of individuals who are not personally involved in HD handling. In a recent study, researchers swabbed workers’ hands and found that a volunteer, oncologist, dietician, and aide who worked in a unit where chemotherapy is administered had exposure that was equal to that of the nurses who directly handled the drugs.

HD residue has been recovered from surfaces inside BSCs, floors in drug preparation, and administration areas, countertops, sinks, computer terminals, telephones, and elevator buttons. At least 15 studies have demonstrated HD residue on the external surfaces of drug vials when delivered from manufacturers. Handling vials without gloves is a source of skin exposure. If vials are not decontaminated before bringing them into the BSC, drug residue can be transferred to other surfaces.

BSCs capture HD aerosols, but do not prevent the generation of contamination. Drug droplets or aerosols produced during the compounding process can contaminate the outside of IV bags and syringes. Crushing tablets, opening capsules, and other drug manipulation outside of a controlled environment cause contamination of the environment with HD residue. PPE used for HD handling can be a vector for transferring drug residue to other surfaces.

Traditional needle-and-syringe techniques often result in leaking. IV tubing and connectors that are not closed systems can result in HD contamination of numerous surfaces in infusion centers, including IV pumps, IV poles, tables, infusion chair arms, and the floor. Small drops of HDs, if not identified and cleaned, are a source of exposure. Closed system transfer devices (CSTDs) are pieces of equipment that contain HDs when they are transferred from one container to another (eg, from vial to syringe or IV container). Ample evidence exists that CSTDs are effective in reducing environmental contamination.

Oncology nurses may consider their work environment free of HD contamination in the absence of a known spill. The evidence does not support that. In the last 24 years, over 100 studies have documented contamination of many surfaces with chemotherapy.

 The frequency and magnitude of contamination vary from one study to another; however, every published study to date has found HD surface contamination when testing for it.

Because surface contamination is invisible, laboratory testing is required to identify it. Documenting contamination, using surface wipe samples, is usually performed in the context of research, but can be an eye-opening exercise in clinical settings. The US Pharmacopeial Convention (USP) in its General Chapter <800>— Hazardous Drugs Handling in Healthcare Settings,

 recommends baseline and periodic sur- face wipe sampling for environmental contamination with HDs. Positive wipe samples not only identify areas of contamination, but also can be used to determine sources of exposure. Follow-up sampling can measure the effectiveness of practices aimed at decreasing contamination.

Some of the challenges related to implementing routine surface wipe sampling for evaluating environmental HD contamination include: limited laboratories that can perform the analysis; the high cost of the assays; the lack of standards for the level of contamination that might be considered “acceptable,” and the level of contamination that requires action. For these reasons, such monitoring is not yet considered routine.

Several strategies exist for reducing nurses’ risk of HD exposure:

Implement CSTDs for all HD administration

Check the security of all infusion equipment connections

Avoid crushing tablets and other manipulation of HDs outside of a containment device

Do not touch items with HD-contaminated gloves. Consider all used PPE contaminated and discard it

Protect surfaces where HD containers are placed with absorbent pads

Institute a thorough process for cleaning and decontamination of areas where HDs are handled

Environmental contamination with HDs is now considered the most likely source of HD exposure for healthcare workers. It is not necessary to wait for laboratory evidence of workplace contamination. The chances are high that HD residue exists wherever the drugs are present. It is time to address the problem of HD residue on work surfaces to minimize nurses’ exposure.

American Cancer Society. Cancer Facts & Figures 2016. 

https://www.cancer.org/research/cancer-facts-statistics/all-cancer-facts-figures/cancer-facts-figures-2016.html

National Institute for Occupational Safety and Health. NIOSH List of Antineoplastic and Other Hazardous Drugs in Healthcare Settings, 2016. 

Polovich M, Clark PC. Factors influencing oncology nurses' use of hazardous drug safe-handling precautions. 

McDevitt JJ, Lees PS, McDiarmid MA. Exposure of hospital pharmacists and nurses to antineoplastic agents. 

Hon CY, Teschke K, Demers PA, Venners S. Antineoplastic drug contamination on the hands of employees working throughout the hospital medication system. 

Sessink PJ, Trahan J, Coyne CW. Reduction in surface contamination with cyclophosphamide in 30 US hospital pharmacies following implementation of a closed-system drug transfer device. 

Shult P. Reducing workplace cytotoxic surface contamination using a closed-system drug transfer device. 

Sessink PJ, Connor TH, Jorgenson JA, Tyler TG. Reduction in surface contamination with antineoplastic drugs in 22 hospital pharmacies in the US following implementation of a closed-system drug transfer device. 

Centers for Disease Control and Prevention. National Institute for Occupational Safety and Health. Occupational Exposure to Antineoplastic Agents and Other Hazardous Drugs: Recent Publications, Guidelines, Review Articles, and Surveys. 

https://www.cdc.gov/niosh/topics/antineoplastic/pubs.html

US Pharmacopeial Convention Chapter <800>: Hazardous Drugs—Handling in Healthcare Settings. 

http://www.usp.org/frequently-asked-questions/hazardous-drugs-handling-healthcare-settings

The chances are high that hazardous drug residue exists wherever the drugs are present. What can nurses do to reduce their risks?


Eye-Opener: Understanding Invisible Hazardous Drug Exposure

New standards for protecting healthcare workers, patients, their families, and the environment from unnecessary exposure to hazardous drugs (HDs) are coming next year. These standards were published in February 2016 by the US Pharmacopeial Convention (USP) in General Chapter <800> Hazardous Drugs—Handling in Healthcare Settings of its National Formulary; they will be officially implemented July 1, 2018.

One of the new requirements is the mandatory use of closed system transfer devices (CSTDs) for the administration of antineoplastic drugs “when the dosage form allows.”

This means that nurses must use CSTDs for chemotherapy agents when the standards become mandatory.

CSTDs are devices that contain HDs when they are transferred from one container to another (eg, from vial to syringe or IV container). The National Institute for Occupational Safety and Health (NIOSH) defines a CSTD as a “drug transfer device that mechanically prohibits the transfer of environmental contaminants into the system and the escape of hazardous drug or vapor concentrations outside the system.”

Currently 10 products are available in the United States with various methods of reducing leaks and capturing HD aerosols. Each has multiple components that work together, such as vial adapters, syringe adapters, and tubing connectors. Parts from different systems are not interchangeable or compatible.

The purpose of CSTDs is to prevent the escape of HDs that may be harmful to healthcare workers while maintaining sterility of the product. Standard IV equipment is designed to protect patient safety (ie, to provide a sterile path for fluids or prevent free-flow). IV components with open-ended tubing, needles, and needleless connectors are open systems that are prone to leaking—which is not dangerous if the leaking fluid is normal saline or 5% dextrose solution.

When handling HDs, however, even small leaks are problematic. In addition to exposure of the individual preparing or administering HDs, leaking results in contamination of the environment with HD residue. That residue becomes an invisible source of exposure for others, even those not directly involved in HD handling or

the care of patients receiving the drugs.

 Nurses may think that if they are careful, their routine drug administration activities will not result in HD leaking and exposure. Multiple studies indicate that is not the case.

 In one study, for example, when nurses primed IV tubing and connected chemotherapy infusions to patients, 30.5% of the time their gloves were contaminated with the drugs.

The effectiveness of CSTDs in containing HDs has been documented since the early 2000s. Substantial published evidence indicates that the use of some of the devices has resulted in a reduction in environmental contamination and worker exposure.

Every CSTD study has demonstrated improved worker safety. USP considered this along with the fact that no other engineering controls exist for HD administration when writing the standards. These devices have the potential to minimize occupational exposure to HDs for nurses and others in areas where these drugs are prepared and administered.

CSTDs are not perfect. The ability to prevent HD exposure varies with the device. There is no performance standard or testing methodology to evaluate manufacturers’ claims of efficacy. Some product components are bulkier than other IV equipment with which nurses are familiar. Other products require nurses to use different techniques. Most require training and practice to learn how to use the devices correctly, and user error may influence containment. An additional barrier is that CSTDs add cost to each dose of drug for which they are used.

CSTDs do not solve all problems related to HD exposure. No CSTD can be used with ampules, so opening ampules and withdrawing HDs is a source of exposure (arsenic trioxide comes in an ampule). Alternative routes of drug administration may require delivery equipment that is incompatible with CSTDs, precluding their use.

Additionally, nurses must remember that any HD contamination on the outside of vials when delivered by the manufacturers is still a source of exposure, and will not be affected by CSTD use.

 Hazardous drugs and USP 800: implications for nurses. bit.ly/2mJ1IFg

 The evolution of the CSTD. bit.ly/2mmaXjE

 Closed-system transfer devices for safe handling of injectable hazardous drugs. bit.ly/2nfhP1q

When making decisions about which device to purchase, organizations must identify the CSTD that best fits with the needs of the setting. An interdisciplinary group should be involved in product selection, including pharmacists and nurses who will use the devices. The evaluation team should examine product information, including published studies supporting their containment. Compatibility with other IV equipment and ease of use should be considered. Product trials conducted under usual working conditions allow staff to see how well CSTDs fit the drug administration procedures of the practice setting.

Although barriers exist to implementing new equipment for drug administration, CSTDs represent a huge step forward for HD safety of nurses. Organizations in which CSTDs are not currently used must begin the process of incorporating these devices into practice as soon as possible, with full compliance expected by July 2018.

2. Centers for Disease Control and Prevention. National Institute for Occupational Safety and Health. NIOSH Alert: Preventing Occupational Exposures to Antineoplastic and Other Hazardous Drugs in Health Care Settings. 

3. Hon CY, Teschke K, Shen H, et al. Antineoplastic drug contamination in the urine of Canadian healthcare workers. 

4. Hon CY, Teschke K, Demers PA, Venners S. Antineoplastic drug contamination on the hands of employees working throughout the hospital medication system. 

5. Connor TG, DeBord, Pretty JR, et al. Evaluation of antineoplastic drug exposure of health care workers at three university-based US cancer centers. 

6. Connor TH, Anderson RW, Sessink PJ, et al. Surface contamination with antineoplastic agents in six cancer treatment centers in Canada and the United States. 

7. Friese CR, McArdle Zhao T, et al., Antineoplastic drug exposure in an ambulatory setting: a pilot study. 

8. Rioufol C, Ranchon F, Schwietz V, et al. Administration of anticancer drugs: exposure in hospital nurses. 

9. Sessink PJ, Trahan J, Coyne JW. Reduction in surface contamination with cyclophosphamide in 30 us hospital pharmacies following implementation of a closed-system drug transfer device. 

10. Siderov J, Kirsa S, McLauchlan R. Reducing workplace cytotoxic surface contamination using a closed-system drug transfer device. 

11. Sessink PJ, Connor TH, Jorgenson JA, Tyler TG. Reduction in surface contamination with antineoplastic drugs in 22 hospital pharmacies in the US following implementation of a closed-system drug transfer device. 

Nurses may think that if they are careful, their routine drug administration activities will not result in hazardous drug leaking and exposure, but even small leaks are problematic.

New Safety Requirements for Nurses Handling Antineoplastic Agents

Concern about safe handling of hazardous drugs (HDs) now goes back more than a generation to the 1970s. Several chemotherapy agents were linked to secondary malignancies in treated patients, and astute clinicians suspected that healthcare workers (HCWs) might also be at risk. Data demonstrating the harmful effects of occupational chemotherapy exposure soon followed, all of which pointed to the need for protecting pharmacists and nurses.

Despite agreement among key stakeholders who support HCW safety when handling HDs, (Occupational Safety and Health Administration [OSHA]

National Institute for Occupational Safety and Health [NIOSH],

 American Society of Health System Pharmacists,

 there remains considerable variation in the use of safety precautions. Two of the most common misconceptions about HD exposure and HD precaution are (1) the chance of being exposed is small, and (2) there is no evidence to support all the recommended precautions.

Most oncology nurses accept the fact that HDs are harmful, and that exposure should be avoided.

 Yet, what some clinicians fail to recognize is that they are potentially exposed when performing routine handling activities or that they might be personally vulnerable to the adverse effects of exposure. Recent studies

 indicate nurses’ HD exposure is frequent enough to warrant concern (

Many studies have detected HD residue on surfaces in healthcare settings,

 if nurses touch them without wearing personal protective equipment (PPE). Such contamination can occur from small leaks or from the transfer of HD residue from the outside of drug containers or gloves. The occurrence of environmental contamination has not improved significantly in the last 10 years.

 Some now consider this “invisible” contamination one of the most common sources of HCW exposure.

Table 1. Hazardous Drug Exposure Reported by Nurses

Several studies using biological monitoring documented the occurrence of occupational exposure by measuring HD residue in urine

 and genotoxic changes in peripheral lymphocytes of HCWs.

 A recent meta-analysis confirmed the overall effect of genotoxic damage as a result of occupational HD exposure.

 Whereas the magnitude of occupational exposure is likely small, the frequent, low-level exposure has potential adverse effects.

The HD safe handling precautions recommended in the 1980s were based on the best evidence available at the time. More than 30 years later, ample data exist to support biological safety cabinets (BSCs), closed system transfer devices (CSTDs), PPE, and a comprehensive safe handling program.

BSCs and other types of ventilated cabinets are engineering controls designed for the purpose of protecting workers by preventing HDs from escaping into the work environment during drug preparation. Two examples of studies demonstrate the protective nature of BSCs. HCWs who do not use BSCs are exposed when compared to those who used them as evidenced by DNA damage.

 When BSCs malfunction, they have been associated with exposure.

Table 2. Components of a Comprehensive Hazardous

CSTDs are supplemental engineering controls. CSTDs are not used as commonly as other HD precautions, yet they represent the only engineering control available for HD administration. There are multiple studies demonstrating reduced surface contamination, which is a source of HCW exposure,

 as well as a decrease in actual HCW exposure.

PPE—both gowns and gloves&mdash;provide barrier protection for HCWs when handling HDs. There are studies that demonstrate decreased worker exposure when PPE is worn compared with no PPE.

 In addition, contamination found on the outside of gowns and/or gloves would have resulted in worker exposure had they not been wearing PPE.

Evidence exists to support the effectiveness of comprehensive safe handling programs for HD exposure control measures.

 Such programs address all aspects of HD handling, since combining strategies is more likely to result in worker safety (

 endorsed double-gloving, chemotherapy-tested gowns and external venting of BSCs in  2004 . These recommendations appeared in the OSHA guidelines in the 1990s,

 although many considered these “suggestions,” and therefore optional.CSTDs are the only novel tools for safe handling of HDs, and the oldest of these has more than 15 years of data to support their use.

Because few recommendations for HD safe handling are new, it is unlikely that the inconsistent use of precautions is due to lack of awareness. Barriers to safe handling precautions do exist (

Although some barriers are out of the control of HCWs and rest in the hands of facility leaders, others are due to perceptions and misconceptions of individuals. Attitudes about the low risk of exposure and the remote health effects may contribute to failure to use precautions

• Lack of availability of chemotherapy-tested PPE

• Not being convinced of the need for PPE

• Concern that patients will be scared or worried when staff wear PPE

Believing that PPE use is a “personal choice” is not harmless. Novice nurses learn from experienced nurses they respect. By modeling unsafe behavior, nurses send a message that exposure is not serious.

Because behavior change is related as much to attitudes and beliefs as it is to knowledge and skills, HD safety education must identify and address the affective domain. There should be a balance between fear and respect for those who are concerned about exposure. Because HD exposure and its potential for harm is not a matter of faith (ie, “I don’t believe it”), but one of toxicology, nurses must accept their personal susceptibility and value the precautions that are available.

1. US Department of Labor. Occupational Safety and Health Administration. Controlling Occupational Exposure to Hazardous Drugs. 

https://www.osha.gov/SLTC/hazardousdrugs/controlling_occex_hazardousdrugs.html

2. Centers for Disease Control and Prevention. The National Institute for Occupational Safety and Health. NIOSH List of Antineoplastic and Other Hazardous Drugs in Healthcare Settings, 2016. 

3. American Society of Health-System Pharmacists. ASHP Guidelines on Handling Hazardous Drugs. 

4. Polovich M, Olsen M, LeFebvre KB, eds. Chemotherapy and Biotherapy Guidelines and Recommendations for Practice. 4th ed. 2014; Oncology Nursing Society: Pittsburgh, PA.

5. Polovich M, Clark PC. Factors influencing oncology nurses' use of hazardous drug safe-handling precautions. 

6. Boiano JM, Steege AL, Sweeney MH. Adherence to precautionary guidelines for compounding antineoplastic drugs: a survey of nurses and pharmacy practitioners. 

7. Boiano JM, Steege AL, Sweeney MH. Adherence to safe handling guidelines by healthcare workers who administer antineoplastic drugs. 

8. Friese CR, McArdle C, Zhao T. Antineoplastic drug exposure in an ambulatory setting: a pilot study. 

9. Friese CR, Himes-Ferris L, Frasier MN, et al. Structures and processes of care in ambulatory oncology settings and nurse-reported exposure to chemotherapy. 

10. He B, Mendelsohn-Victor K, McCullagh MC, Friese CR. Personal protective equipment use and hazardous drug spills among ambulatory oncology nurses. 

11. Berruyer M, Tanguay C, Caron NJ, et al. Multicenter study of environmental contamination with antineoplastic drugs in 36 Canadian hospitals: a 2013 follow-up study. 

12. Bussieres JF, Tanguay C, Touzin K, et al., Environmental contamination with hazardous drugs in Quebec hospitals. 

13. Connor TH, DeBord DG, Pretty JR, et al., Evaluation of antineoplastic drug exposure of health care workers at three university-based US cancer centers. 

14. Ladeira C, Viegas S, Padua M, et al. Assessment of genotoxic effects in nurses handling cytostatic drugs. 

15. Centers for Disease Control and Prevention. The National Institute for Occupational Safety and Health. NIOSH Alert: Preventing Occupational Exposures to Antineoplastic and Other Hazardous Drugs in Health Care Settings. 

16. Connor T, DeBord DG, Pretty J. Evaluation of antineoplastic drug exposure of health care workers at three university-based US cancer centers. 

17. Connor TH, Anderson RW, Sessink PJ, et al., Surface contamination with antineoplastic agents in six cancer treatment centers in Canada and the United States. 

18. Hon CY, Teschke K, Shen H, et al. Antineoplastic drug contamination in the urine of Canadian healthcare workers. 

19. Miyake T, Iwamoto T, Tanimura M, Okuda M. Impact of closed-system drug transfer device on exposure of environment and healthcare provider to cyclophophamide in Japanese hospital

20. Bouraoui S, Brahem A, Tabka F, et al. Assessment of chromosomal aberrations, micronuclei and proliferation rate index in peripheral lymphocytes from Tunisian nurses handling cytotoxic drugs. 

21. McDiarmid MA, Olier MS, Roth TS, et al. Chromosome 5 and 7 abnormalities in oncology personnel handling anticancer drugs. 

22. McDiarmid MA, Rogers B, Oliver MS. Chromosomal effects of non-alkylating drug exposure in oncology personnel. 

23. Moretti M, Grollino MG, Pavanello S, et al. Micronuclei and chromosome aberrations in subjects occupationally exposed to antineoplastic drugs: a multicentric approach. 

24. Villarini M, Gianfredi V, Levorato S, et al., Occupational exposure to cytostatic/antineoplastic drugs and cytogenetic damage measured using the lymphocyte cytokinesis-block micronucleus assay: a systematic review of the literature and meta-analysis. 

25. Crickman R, Finnell D. Systematic review of control measures to reduce hazardous drug exposure for health care workers. 

26. Fuchs J, Hengstler JG, Jung D, et al. DNA damage in nurses handling antineoplastic agents. 

27. Kevekordes S, Gebel TW, Hellwig M, et al., Human effect monitoring in cases of occupational exposure to antineoplastic drugs: a method comparison. 

28. Clark BA, Sessink P. Use of a closed system drug-transfer device eliminates surface contamination with antineoplastic agents. 

29. Favier B, Labrosse H, Gilles-Afchain L, et al. The PhaSeal system: Impact of its use on workplace contamination and duration of chemotherapy preparation. 

30. Fransman W, Vermeulen R, Kromhout H. Dermal exposure to cyclophosphamide in hospitals during preparation, nursing and cleaning activities. 

31. Sottani C, Porro B, Imbriani M, Minola C. Occupational exposure to antineoplastic drugs in four Italian health care settings. 

32. Keat CH, et al. Improving safety-related knowledge, attitude, and practices of nurses handling cytotoxic anticancer drugs: pharmacists' experience in a general hospital, Malaysia. 

33. Sproll B, Milan H, Caligiuri C, et al. Development and implementation of a regional program for safe handling of hazardous drugs by hospital pharmacies. 

34. Yoshida J, Koda S, Nishida S, et al, Association between occupational exposure and control measures for antineoplastic drugs in a pharmacy of a hospital. 

35. US Department of Labor. Occupational Safety and Health Administration. Controlling Occupational Exposure to Hazardous Drugs in OSHA Technical Manual; 1999.

Despite the warnings, adherence to safe handling precautions by healthcare practitioners is uneven; understanding the risks are essential.

Martha A. Polovich, PhD, RN, AOCN

Articles

Hazardous Drugs and Reproductive Effects: Understanding the Risks

Eye-Opener: Understanding Invisible Hazardous Drug Exposure

New Safety Requirements for Nurses Handling Antineoplastic Agents

Attitude Shift: Making Safe Handling of Hazardous Drugs a Priority