HAZARDOUS DRUGS

Effective Date: 
Tue, 07/30/2019
Revised: 
Tue, 01/26/2021
Policy: 

All pharmacies and clinical offices that dispense or administer hazardous drugs (HD) must follow the USP <800> and EPA guidelines.

Any drug that demonstrates evidence of carcinogenicity, teratogenicity, genotoxicity, reproductive, developmental toxicity, or organ toxicity at low doses, are included on the site specific list of Hazardous Drugs. Those drugs are included in NIOSH tables - Table 1 (antineoplastics), Table 2 (other hazards), and Table 3 (reproductive hazards).

The requirements for the Student Health Center include:

  • Assessment of risk
  • Hazard communication
  • Annual review
  • Training of applicable staff for receiving, storage, transport, administration, disposal and clean up

The UCSC Student Health Center orients all new staff regarding Illness and Injury Prevention (IIPP), including Hazard Communication, upon hire, with specific training depending on their work area and job description.  Similarly, applicable staff are trained whenever a new product or a new procedure is instituted.  HD products are included in the Safety Data Sheets (SDS').

The UCSC Student Health Center pharmacy staff do not compound, nor physically touch, cut or crush any of the hazardous drugs that are stocked, therefore, no special handling, labeling or packaging is required (see attachments). If cutting or crushing of an HD is needed, the student can acquire a pill cutter or crusher for individual use.  If there is any risk, staff can use gloves.

Nursing staff administer estrogen, progesterone and testosterone products, and use the appropriate Personal Protective Equipment (PPE).

Procedure: 

Designated Person and Designated Area

The UCSC Pharmacy is the lead department regarding following the requirements for hazardous drugs for UCSC Student Health Services.  The designated person in charge is the Pharmacist-in-Charge (PIC), and the designated area is the receiving area of the pharmacy. 

New products that are ordered and received will be entered into the Pharmacy software and will be reviewed against the NIOSH lists (and Confused Drug Names and High Alert Medications List ISMP list), for special handling, documentation/inclusion on the UCSC list, and any futher documentation in the Pharmacy software.  Hazardous drugs from wholesalers/suppliers are packaged separately from other medications and are double bagged.  The pharmacy staff receiving any new products will alert pharmacist/s of any new HD's (or new products on the ISMP Confused Drug Names and High Alert Medications Lists).

An annual assessment will be performed and an annual report will be made to the Pharmacy and Therapeutics Committee.

Assessment of Risk

All stocked drugs from the NIOSH Tables are assessed for risk.  See UC SHS NIOSH Hazardous Drugs shared document for risk and special handling.  New drugs are added upon order / receipt with risk assessment conducted.  Document is reviewed at least annually.

The UCSC Pharmacy department may designate that staff of reproductive capability or are pregnant or conceiving refrain from dispensing specific medications as listed in the Risk Assessment on the UC SHS NIOSH Hazardous Drugs shared document regarding risk and special handling.

Hazard Communication and Training

All staff who may come into contact with hazardous drugs (pharmacists, pharmacy technicians, nurses) will complete the Learning Center training on Hazardous Drugs.  Note: Special attention for staff with reproductive capability.

Labeling, Packaging, Transport and Disposal

The UCSC Student Health Center does not physically touch, cut or crush any of the hazardous drugs that are stocked, therefore, in general, no special handling, labeling or packaging is required for intact HD's. HD's are obviously designated with an HD label, and are separated from other drugs on the shelf via small bins (see attachments).  

Special Handling: The UCSC Pharmacy department may designate that staff who are pregnant or conceiving refrain from dispensing specific medications as listed in the Risk Assessment on the UC SHS NIOSH Hazardous Drugs shared document regarding risk and special handling.  When there is a risk of exposure, staff can use gloves.

UCSC Pharmacy staff will use a designated counting tray, and will refrain from using the shared KL counting machine.  The counting tray will be cleaned before and after counting a hazardous drug.

Spill or Alteration of Dosage Form: If a product is received and has been damaged, or a spill occurs, then clean up would be done using a spill kit with any involved staff member wearing Personal Protective Equipment (PPE) including the appropriate gloves and an N-95 respirator. 

Disposal: Any waste HD product will be contained and sequestered, then disposed of appropriately depending on the hazard. See UC SHS NIOSH Hazardous Drugs shared document for risk and special handling.  As needed, the product will be entered into the online UCSC WASTe system by designated users, for pick up and disposal by EH&S.

Administration

Nursing staff administer estrogen, progestins and testosterone products by injection and wear gloves for withdrawing contents from a vial and for administering the medication to patients.