Should I Still Worry About Hazardous Drugs as an Oncology Nurse?

Hazardous drugs are defined as carcinogenic, developmentally toxic, reproductively toxic, organ toxic, or genotoxic, or new drugs that have a similar structure or toxicity to drugs classified as hazardous.¹ These drugs are widely used in the oncology setting, increasing the risk of exposure significantly for nursing staff and those who work in the pharmacy. Despite the evolution of safety guidelines from organizations such as the National Institute for Occupational Safety and Health (NIOSH), Oncology Nursing Society (ONS), and United States Pharmacopeia (USP), a heightened fear continues to exist among those working with these agents. These apprehensions stem from the occupational risks associated with adverse outcomes, including nausea, vomiting, rash, diarrhea, infertility, miscarriages, and chromosomal changes that can lead to cancer following repeated exposure.²

The Evolution of National Guidelines

In 1986, OSHA published its first guidelines for health care workers on how to manage antineoplastics safely. Since then, ONS and NIOSH have continued to highlight the value of ongoing education. These educational strategies explain how hazardous drugs should be stored, prepared, labeled, transported, administered, and disposed of, as well as the appropriate personal protective equipment required to do so. In 2016, the USP further advanced these efforts through additional updates on safe handling and the ongoing need for health care workers to maintain demonstration of competency, which were made official in 2019.³

Later in 2016, NIOSH published an updated list of hazardous drugs, categorizing them into 3 distinct groups.⁴ Group 1 comprised antineoplastic drugs, group 2 included nonantineoplastic drugs that met at least 1 NIOSH criterion for hazardous drugs, and group 3 consisted of drugs linked with reproductive risk. By 2024, these categories were consolidated into 2 tables that classified hazardous drugs based on their carcinogenic potential, based on whether a drug has manufacturer’s special handling information in its package insert, or meets the NIOSH definition of a hazardous drug and is known to be carcinogenic per the National Toxicology Program or the International Agency for Research on Cancer. The 2024 update led to the addition of 25 antineoplastic drugs and the removal of 7 others, despite their ongoing use in cancer treatment, reflecting updated handling recommendations.²

The institutional risk assessments that are conducted to determine if a drug is hazardous are a requirement of the USP <800> standards, and each organization must perform them annually.³ These assessments are implemented by the pharmacy department and include the following: the type of hazardous drug, dose form, risk of exposure, packaging, and manipulation. Despite these regulations dictated by pharmacy experts, the reclassifications of hazardous drugs have not been widely embraced by frontline oncology staff as a positive change. Many have expressed concern regarding the long-term impact of exposure to nonhazardous drugs that may later be placed back on the hazardous drug list.

How Do Oncology Nurses Remain Safe?

As an oncology nurse, it is important to first educate oneself on the evolution of safe handling and the risk of exposures. Since the evolution of evidence-based guidelines in 1986, there have been ongoing strategies to continue to keep health care workers working with hazardous drugs safe. These include recognition of hazardous vs nonhazardous drugs, cleaning with germicidal agents that deactivate hazardous drugs, strict guidelines for drug preparation, closed system transfer devices on all hazardous drugs, enhancement of personal protective equipment, defined processes for hazardous drug spills, internal organizational safety precautions, annual drug risk assessments, and ongoing education.

Secondly, it is important to remember that the risk of exposure begins from the moment these hazardous drugs are received in the pharmacy department. Ongoing cleaning with germicidal agents and compliance with personal protective equipment are critical components of the hierarchy of controls. If each health care worker begins by complying with every encounter of storage, preparation, labeling, transporting, administering, and disposing, this would significantly reduce the risk of occupational exposure. Additional control measures, such as closed system transfer devices, externally ventilated biological safety cabinets, and ongoing training, also reduce indirect (as well as direct) exposures.⁴

Thirdly, medical surveillance is an early identifier to detect health changes and reversible effects of exposure, and prevent adverse outcomes.⁵ This strategy can range from health assessments, questionnaires, physical exams, laboratory testing, and postexposure follow-up. Routine surveillance can be a valuable method for early intervention and reducing risk for long-term health complications.

And finally, for nurses who are actively trying to conceive or are pregnant or breastfeeding, organizations should also have a process in place to support oncology nurses by maintaining their safety. From the moment a nurse begins this journey, it is important to advocate for oneself by informing their employer. This is extremely critical to reduce any accidental exposures that could lead to birth defects. This will also allow employers the opportunity to provide a protective reassignment or alternative duty.¹

References

1. Whittaker C, Ovesen JL, MacKenzie BA, Hartley T, Berry KA, Piacentino J. Procedures for developing the NIOSH list of hazardous drugs in healthcare settings. National Institute for Occupational Safety and Health. 2023. November 13, 2025. doi:10.26616/NIOSHPUB2023129
2. Ovesen JL, Sammons D, Connor TH, et al. NIOSH list of hazardous drugs in healthcare settings, 2024. National Institute for Occupational Safety and Health. December 2024. Accessed November 13, 2025. doi:10.26616/NIOSHPUB2025103
3. <800> Hazardous Drugs–Handling in Healthcare Settings. United States Pharmacopeia. Accessed November 14, 2025. https://www.usp.org/compounding/general-chapter-hazardous-drugs-handling-healthcare
4. Friese CR, Wong M, Fauer A, Mendelsohn-Victor K, Polovich M, McCullagh MC. Hazardous drug exposure: case report analysis from a prospective, multisite study of oncology nurses' exposure in ambulatory settings. Clin J Oncol Nurs. 2020;24(3):249-255. doi:10.1188/20.CJON.249-255
5. Toolkit for Safe Handling of Hazardous Drugs for Nurses in Oncology. Oncology Nursing Society. 2018. Accessed November 13, 2025. https://www.ons.org/sites/default/files/2018-06/ONS_Safe_Handling_Toolkit_0.pdf