Hazardous to Handle Policy @ HCMC

The Hazardous to Handle Medication Policy and the Pharmaceutical Waste Policy have been revised, approved and reposted as on-line Policies.  Many people were involved with these revisions, including interdisciplinary staff, management, clinicians, unions, and legal. Changes are effective immediately. Much of this information was presented in July and August as Medication Management and Waste Management presentations as part of Joint Commission preparation for managers and supervisors.
There are several significant changes that all staff need to be aware of: 
1)    Reproductive category employees (those attempting to conceive, pregnant women, women who are breast–feeding), may request reassignment to comparable duties that do not involve the handling or administration of High Risk hazardous to handle drugs. This request is made to the manager in their assigned area. Due to negligible risk when appropriate protective apparel is worn, staff in the reproductive category will not be reassigned if they are assigned to a patient receiving Low Risk or Reproductive Risk H2H medications or who has received them in the past 48 hours. Reassignment will only be allowed as safe staffing permits. All employees will use personal protective apparel and equipment per policy to limit exposure.
2)    For Hazardous to Handle (H2H) medications, precautions are in effect for 48 hours after the last dose (previously 7 days). We currently have very few H2H drugs on formulary that would remain unchanged in significant levels in the body for greater than 48 hours. 
3)   Empties go in regular trash:
Almost all pharmaceutical empty packaging (vials/syringes/bottles/bags/wrapperscan now goes in regular trash IF all patient identifiers are removed.  This includes empty controlled substance packaging.
          Exceptions are:
o    Chemotherapy medication empties must go in the Yellow Chemo Trace waste containers.
o    Needles/sharps
o    EPA P-List Drugs (only 5 on formulary: nicotine, nitroglycerin, phenol, physostigmine, warfarin) in all forms, including empty containers/packaging and partials, must be bagged and placed in a Pharmaceutical Waste container (“black box”).
4)    NON-chemo H2H medications disposal:
o    Empties go in regular trash
o    Partials go in Pharmaceutical waste containers (“black box”)
5)    Warfarin is no longer included on the H2H list and H2H requirements no longer apply. This is done to comply with EPA P-list rules.
6)   Inhaled hazardous to handle medications are always administered by Respiratory Therapy staff.
7)    Closed system transfer devices are applied to intravenous H2H drugs by pharmacy to help prevent leakage. However, all IV connections, sets and pumps should be observed for leakage during use. A Plastic-backed, absorbable, disposable underpad should be placed under the tubing during disconnection or during IV push doses to catch any leakage.
8)   Personal Protective Equipment
o   Optional but suggested if the work can result in a spray, splash, or aerosol that could expose the employee’s eye, nose, or mouth to a hazardous drug: full face shield or goggles should be used. Eyeglasses with temporary side shields are not acceptable.
o    Shoe cover language removed except for spills and pharmacy Clean Room preparation.
o    Less restrictive for Reproductive category employees administering reproductive risk H2H medications: only nitrile or neoprene gloves are required. 
9)   Care of the patient:
o    Patients and families of patients identified as receiving High Risk H2H drugs will receive standard education
o    No more labeling of lab samples or other H2H-related lab requirements.
o    Labeling of urinals, basins, etc , only for High Risk drugs
10) Patient Wastes:  
o    For patients receiving low risk or reproductive risk H2H medications within the past 48 hours, no special precautions are required.
o    For high risk only
o    To dispose of eliminations, staff will don face and eye protection before flushing toilet. Alternatively, the toilet may be covered with a disposable plastic-backed absorbent pad (chucks pad) prior to flushing. Use of gowns is also recommended.
o    Rinse urinals, bedpans, and commodes two to three times. Used containers that are no longer needed should be sealed in a double bag and placed in the regulated medical waste.
11) Supply Disposal:
o    Non-chemo H2h: empties to regular trash; sharps to regular sharps; partials to Pharm Waste container (black box)
o    Chemotherapy (high or low risk): empties to Chemo Trace Waste container; sharps to Chemo Sharps container; partials return to pharmacy to Chemo Bulk waste container
o    All unused product returned to pharmacy.
12)                H2H Med List Changes:
o   Products added:
o   Entecavir oral : non-chemo, low risk, h2h warning added when drug added to formulary, antiretroviral for hepatitis
o   EriBULin inj: chemo, high risk, Chemo/H2H warning added when drug added to formulary.
o   ADO-Trastusumab Emtansine (Kadcyla) inj : chemo, high risk, has H2H warning in admin instruction but not Label comment, dispense code chemo
o   Bosutanib oral, chemo, low risk, already has H2H warnings, missing chemo designation
o   Histrelin acetate sq implant, chemotherapy adjuvant, reproductive risk. 
o   Products removed
o   warfarin oral and injection (moved to EPA P-List)
o   Product changed from high risk to low risk:
o   Azathioprine injection

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