Nurses Should Advocate for Better Safety Standards for Hazardous Drugs

Precautions should be taken when handling chemotherapy and other hazardous drugs, as they can cause acute or chronic effects in nurses and healthcare providers.

A lot of attention is given to the long-term effects of chemotherapy seen in patients with cancer, but handling chemotherapy and other hazardous drugs can also cause acute or chronic effects in nurses or other healthcare providers, and they may be exposed to these hazardous drugs more often than they realize.

In a 2013 study, Hon et al tested 229 frequently contacted surfaces within a hospital medication system and found that 36% of samples taken were positive for the presence of cyclophosphamide.[1] The study found contamination in a variety of places, including on a computer mouse and elevator buttons. A second study by Hon et al published in 2014 took 225 hand wipe samples and found that one in five samples were positive for cyclophosphamide.[2]

“I think if we looked at these drugs as bags of Ebola instead of bags of drugs, we might think about how we handle them a little differently,” said Seth Eisenberg, RN, ASN, OCN, BMTCN, a professional practice coordinator, infusion services at Seattle Cancer Care Alliance.

At the Oncology Nursing Society (ONS) 41st Annual Congress held April 28 to May 1 in San Antonio, Texas, Eisenberg and AnnMarie Walton, PhD, MPH, RN, OCN, CHES, a postdoctoral fellow at University of North Carolina at Chapel Hill School of Nursing, gave a presentation designed to provide oncology nurses with more knowledge about handling hazardous drugs, as well as inspiration on how to make changes in the work environment or in the state where they practice.

Current Guidelines

Controlling exposure to occupational hazards is a fundamental part of protecting healthcare workers, according to the National Institute for Occupational Safety and Health (NIOSH). Eisenberg discussed a hierarchy of controls used by NIOSH to determine how to implement control solutions. Level 1 controls, or those considered to be the most effective, involve elimination or substitution of the hazard, something that is not possible in the case of chemotherapy. Level 2 controls are engineering controls. Level 3 controls are administrative controls, such as policies and procedures on how to do things properly, and Level 4 controls involve personal protective equipment (PPE).

Currently, oncology nurses have the most control over their use of PPE, according to Eisenberg. Current recommendations call for double gloving with American Society of Testing and Materials–tested chemotherapy gloves, wearing chemotherapy-resistant gowns during all stages of drug handling, and using a closed system transfer device (CSTD) for compounding and administration.

In addition, guidelines call for the use of a Biologic Safety Cabinet when cutting or crushing oral hazardous drugs, making spill kits available, and training all personnel in hazardous drug handling.

However, Eisenberg pointed out that NIOSH is a research arm of the Centers for Disease Control & Prevention (CDC) and does not have an enforcement capability, and the Occupational Safety and Health Administration (OSHA) does not have the resources available for enforcement.

Newer to the hazardous drug handling arena is the United States Pharmacopeial Convention (USP), a pharmacy-based quality organization, who has published standards for hazardous drug handling, from delivery to the hospital through administration and disposal in its General Chapter <800>. According to Eisenberg, this organization is now dictating safe handling practices to oncology nurses.

“I think this is good news because unlike NIOSH, who can’t do anything about this problem, the USP <800> is being enforced,” Eisenberg said.

The USP <800> requires the use of double gloves and chemotherapy-resistant gowns. It also requires spill training and the use of appropriate respiratory protection for drugs that vaporize at room temperature. In addition, the use of a CSTD will be required for administration.

Making Changes

During the second part of the presentation, Walton and Eisenberg discussed ways in which oncology nurses can get involved in advocating for safety in handling hazardous drugs.

“There is a lot that we can do individually and collectively about PPE, as well as about our hospitals policies,” Walton said. “While they may not be as effective at minimizing exposures, it is a really empowering place to start and can lead to other things.”

Walton shared a story from her time at the North Carolina Cancer Hospital where a pediatric oncology nurse approached the adult oncology nurses with a question about how to handle the safety of parents who were changing diapers of patients undergoing chemotherapy and being exposed to chemotherapy through excrement.

“The question made us pause,” Walton admitted. She and her colleagues were forced to look further into what policies existed for handling excrement, for what to tell caregivers who helped patients toilet, and for healthcare workers who handled post-administration waste.

After identifying several gaps in the hospital’s policies, Walton and her colleagues worked to establish several changes to increase safety. For example, they had two types of gloves available on the ward, regular gloves and chemotherapy gloves, but made the decision to change all of the gloves to chemotherapy gloves. In addition to practice changes, they worked to train and educate not only nurses but all ancillary staff including nursing assistants, housekeeping, or anyone else coming into contact with patient excrement and hazardous materials.

“Families noticed that we were making these changes in practice and we had to make education materials to begin teaching caregivers about handling hazardous drug waste while in the in-patient setting,” Walton said. They also created signs about handling hazardous waste for use throughout patient areas and anywhere that hazardous drugs were received, including transplant, intensive care units, or other non-oncology settings.

Organizational level changes only require an advocate or champion, but changes on a greater level are also possible with just one voice, Eisenberg said. In Washington, where he practices, a patient’s daughter approached two state legislators about a lack of legislation dealing with the safe handling of hazardous drugs. Her mother had been a hospital pharmacist for 20 years, frequently exposed to hazardous drugs, and was now dealing with pancreatic cancer.

The daughter convinced the legislators of the issue’s importance and they helped pass two bills (SB-5594 and SB-5149) in 2011 to adopt NIOSH guidelines as state law for the handling of hazardous drugs. Although the law was passed in 2011, it did not go into full effect until January 2016. Eisenberg said that the state did not do a good job of informing hospitals and physicians that this law was passed, and that the state ran into a large amount of resistance about the enforcement of the law by doctors or facilities who said that they could not afford to comply with the requirements.

Despite these temporary roadblocks, he said that the example of Washington shows that enacting a state law can begin with just a single voice. He encouraged all nurses to get involved in advocating for their own safety when it comes to handling hazardous drugs.


1. Hon Cy, Teschke K, Chu W, et al. Antineoplastic drug contamination of surfaces throughout the hospital medication system in Canadian hospitals. J Occup Environ Hyg. 2013;10:374-83.

2. Hon CY, Teschke K, Demers PA, et al. Antineoplastic drug contamination on the hands of employees working throughout the hospital medication system. Ann Occup Hyg. 2014;58:761-70.