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Preventing Non-therapeutic Exposure to Hazardous Drugs ( 6.1.11)

Preventing Non-therapeutic Exposure to Hazardous Drugs ( 6.1.11) - Policies, Clinical, UW Health Clinical, Medications and Pharmacy


Policy Title: Preventing Non-therapeutic Exposure to Hazardous Drugs
Policy Number: 6.1.11
Category: UW Health
Type: Ambulatory and Inpatient
Effective Date: October 2, 2017


To ensure that exposure to hazardous drugs (HDs) is minimized for staff, family, and visitors.


Containment Primary Engineering Control (C-PEC): A ventilated device designed and operated to
minimize worker and environmental exposures to HDs by controlling emissions of airborne contaminants.

Hazardous Drug: drugs that are known or suspected to cause adverse health effects. Any drug that exhibits
one or more of the following six characteristics in humans or animals is defined as hazardous:
carcinogenicity, teratogenicity, reproductive toxicity, organ toxicity at low doses, genotoxicity, mutagenicity or
other toxic effects. New drugs may be defined as hazardous due to structural similarities to drugs that are
already designated as hazardous.

Personal Protective Equipment (PPE): Protective clothing, goggles, gloves, shoe covers or other
garments and equipment designed to protect from injury or contamination.


UW Health is committed to promoting safe practices for those who handle, prepare, administer, or are
otherwise exposed to hazardous drugs. Staff is educated on safe practices to minimize non-therapeutic
hazardous drug exposures for staff, patients, families, students, and visitors. Personal protective equipment,
engineering controls and medical surveillance programs are available for healthcare workers as a
comprehensive approach to prevent and monitor hazardous drug exposures.


A. UW Health Hazardous Drug List
i. The Pharmacy and Therapeutics Committee is responsible for the oversight of the UW Health
Hazardous Drug List.
ii. Determining hazardous drugs
a. The criterion for hazardous designation is inclusion on the published National Institute for
Occupational Safety and Health (NIOSH) List of Antineoplastic and Other Hazardous
Drugs in the Healthcare Settings (Appendix A).
b. The NIOSH list is published biennially. Therefore, during interim periods, the Drug Policy
Program will review newly FDA approved drugs, drugs not subject to FDA oversight (e.g.
nutritional supplements), or established drugs with new safety warnings for consideration
of temporary addition to the list. Such drugs may be removed from the list if they are not
subsequently included on the next published NIOSH list.
iii. Hazardous drug formulations are separated into two categories: High Risk or Low Risk. Two
categories simplify the requirements for PPE and engineering controls. Risk categories represent
risk to the employee performing work related activities.
a. High Risk hazardous drugs are defined as all drugs listed in NIOSH Group 1
(antineoplastic drugs). Exceptions include oral tablets or capsules which are individually
packaged, intact, and not manipulated, see IV.A.iii.b.
b. Low Risk hazardous drugs are defined as all drug formulations listed in NIOSH Group 2
(non-antineoplastic drugs that meet one or more of the NIOSH criteria for a hazardous
drug), NIOSH Group 3 (non-antineoplastic drugs that primarily have adverse reproductive
effects), and NIOSH Group 1 individually packaged intact tablets and unopened capsules.
B. Communication about Hazardous Drugs
i. Employees who are trying to conceive, trying to conceive with a partner, pregnant, or breastfeeding
are encouraged to discuss options with their supervisor about handling hazardous drugs. In
addition, employees are encouraged to speak to Employee Health Services and their personal

Policy Title: Preventing Non-therapeutic Exposure to Hazardous Drugs
Policy Number: 6.1.11

health care provider about how exposure could affect them.
ii. The Pharmacy Department is responsible for informing staff about hazardous drugs. This includes
providing recommendations on the handling and necessary PPE for new drugs. It also includes
providing recommendations for the handling of established drugs if new information becomes
available or hazardous status changes.
a. The actual risk to healthcare workers depends on the following factors:
1. Toxicity of the drug
2. Route of exposure (e.g., dermal, inhalation, or ingestion)
3. Type and frequency of handling and need for manipulation prior to administration
4. Available protections to control exposure such as the type of engineering controls
and PPE
iii. The information systems used by UW Health are:
a. All hazardous drugs, including those not on the UW Health formulary will have an
electronic medication record built within Health Link. The electronic record will indicate
whether the drug is categorized as High Risk or Low Risk to the employee.
b. A warning banner will display in the patient’s electronic chart indicating the patient has an
active or recent order for a hazardous drug.
1. This banner will display until 48 hours after the medication is discontinued.
2. Active or recent orders will be listed within the banner.
3. At minimum the hazardous category will be indicated:
A. HIGH RISK Hazardous Drug
B. LOW RISK Hazardous Drug
c. For inpatient and procedural areas, a Hazardous Drug Precaution Sign (Appendix B) will
be posted on the door to the patient’s room (including both inpatient and procedural
rooms) and bathroom indicating the patient has received hazardous drugs. The sign will
be posted by the nurse (or designee) when administering the first dose of any hazardous
drugs, and will remain in place for a minimum of 48 hours after the last administration or
patient discharge or transfer. The sign will indicate how long hazardous drug precautions
shall remain in place
d. Hazardous drugs prepared or packaged by the Pharmacy Department, including infusion
bags, will be identified with a brightly colored label and/or specific wording which
adequately alert personnel to hazardous contents. All labeling should include the
necessary information to determine appropriate PPE for safe handling. At minimum the
hazardous category will be indicated.
1. Hazardous - High Risk
2. Hazardous - Low Risk
e. Storage areas for hazardous drug inventory (does not include final unit dosage forms) are
also marked with brightly colored signs and labeling which adequately alert personnel to
hazardous contents. Areas include bins, refrigerators and preparation and storage rooms.
iv. Training for appropriate handling is provided at the departmental level. Department managers are
required to ensure all employees who may be exposed to hazardous drugs are provided education
and training before initial assignment.
a. The content of training materials should be aligned with the extent of anticipated exposure
risk. Consideration should be given to the degree of participation in receiving, preparing,
handling, compounding, distribution, administration, environmental management, or
transport of hazardous drugs, their metabolites, or patients receiving hazardous drugs.
Any other activity, not previously specified, in which personnel may be exposed to
hazardous drugs or their metabolites must be considered.
b. At minimum the training must include action necessary to prevent exposure to hazardous
c. All training shall be documented with the following: date(s) of training, summary of
content, names and qualifications of persons conducting the training, and the name,
employee number and job title of the employees attending.
d. Documentation of training will be maintained in an easily accessible format for a minimum
of three years.
v. Family members, primary support caregivers, and visitors at risk of exposure to hazardous drugs
should be informed that they are in the vicinity of hazardous drugs.
a. At risk family members, primary support caregivers, and visitors should be offered a copy
of Health Facts For You (HFFY): Hazardous Drug Safety in the Hospital and at Home

Policy Title: Preventing Non-therapeutic Exposure to Hazardous Drugs
Policy Number: 6.1.11

b. Family members, primary support givers, and visitors should be informed of measures to
minimize their risk:
1. Wash hands with soap and water upon leaving the area.
2. Avoid handling patient’s body fluids or wear nitrile gloves when assisting (i.e.,
parent changing a diaper).
3. Offer pregnant caregivers the option to also wear a disposable gown if it is
necessary to handle patient’s body fluids.
c. Patients and caregivers should obtain education on home management of hazardous
drugs from the health care entity that provides them. Patients should follow the home
health care company’s specific policies and procedures for handling hazardous drugs.
C. Use of Personal Protective Equipment (PPE)
i. PPE is described as:
a. Gloves: Gloves will meet the American Society for Testing and Materials (ASTM)
standards for chemotherapy permeability.
1. Gloves shall always be worn when handling hazardous drugs.
2. Powder free gloves will be used because the powder can contaminate the work
area and adsorb and retain hazardous drug.
3. Gloves should be visually inspected for holes or tears prior to use. Gloves should
be changed according to manufacturer’s recommendation or immediately if torn,
punctured, or contaminated
4. Approved CS Item Description:
A. Gloves Exam Nitrile Powder-Free (all sizes)
B. Gloves Surgical Skinsense (all sizes)
b. Double gloves: Both pairs will be ASTM-tested chemotherapy gloves.
1. If wearing a gown, the inner glove should be worn under the gown cuff and the
outer glove over the gown cuff.
2. For sterile procedures in the Operating Room, two pairs of sterile ASTM tested
gloves will be worn. Refer to section IV.F.ii.
3. Approved CS Item Descriptions:
A. Gloves Exam Nitrile Powder-Free (all sizes)
B. Gloves Surgical Skinsense (all sizes)
c. Gowns: Gowns shall be made of polyethylene-coated polypropylene or other laminate
material tested for hazardous drug permeability. Gowns should be disposable, long
sleeved, cuffed, have a solid front and a closure in the back.
1. Requirements for wearing sterile versus non-sterile gowns shall be determined at
the department level and outlined in written procedures.
2. Gowns are worn whenever there is a possibility of HD contact with skin or
clothing. Clothing may retain HD residue, and personnel may transfer this
residue to patients, family members, staff, or surfaces.
3. Gowns worn for administration or compounding are not to be worn outside the
immediate area to avoid drug contamination.
4. PPE for hazardous drugs will be worn when patients in isolation are receiving
hazardous drugs. The disposable impervious hazardous gown will replace the
isolation gown. The isolation gown cannot replace hazardous PPE.
5. Approved CS Item Descriptions:
A. Gown Disposable Impervious Hazardous (non-sterile)
B. Gown Disposable Sterile Surgical Reinforced (sterile)
d. Eye/Face protection: Appropriate eye and face protection shall be worn for splash risk
when handling hazardous drugs outside an engineering control.
1. A single face shield covering eyes, nose and mouth should be used for each
patient stay. Personnel should disinfect the shield with CaviWipesTM between
each use. The shield should be discarded after patient discharge.
2. Safety glasses can be used in place of a single face shield if respiratory
protection is worn as well.
3. Approved CS Item Descriptions:
A. Shields Splash
B. Glasses Safety
e. Respiratory protection: For activities requiring respiratory protection, an N95 class

Policy Title: Preventing Non-therapeutic Exposure to Hazardous Drugs
Policy Number: 6.1.11

respirator or a powered air purifying respirator (PAPR) will be worn.
1. The N95 respirator mask is a non-powered, respirator for which the user has
been successfully fit tested by style and size and which is in good condition.
A. Employee fit testing shall be performed in accordance to the UW Health
Respiratory Protection Program.
B. For managing spills, N95 masks within the pre-supplied spill kits should
not be worn unless it is the correct size which that individual has been fit
2. The PAPR is a powered respirator mask which does not require fit testing; it
works to remove contaminants from the air by actively passing air through the
air-purifying element before it reaches the user.
3. Surgical masks do not provide respiratory protection from hazardous drug
exposure and should not be worn in place of an N95 class respirator.
ii. General PPE Principles
a. Additional more conservative precautions are optional at the discretion of the employee.
Employees are encouraged to consult with their supervisor and or personal physician
regarding the benefit of additional precautions.
b. Hand hygiene shall be performed in accordance with UW Health clinical policy #4.1.13,
Hand Hygiene.
1. All personnel are required to wash hands with soap and water immediately after
handling hazardous drugs or at the first opportunity when facilities, operations,
and/or patient safety outweighs the risk of delaying hand washing.
2. Hand washing is encouraged whenever gloves are changed.
c. Hazardous waste disposal shall be performed in accordance to UW Health Hazardous
Material and Waste Management Plan.
1. All PPE worn when handling hazardous drugs should be deemed contaminated
and should be disposed of appropriately.
iii. PPE Required for Work Activities
a. Table 1 provides PPE requirements for activities or situations encountered. Questions
about the appropriate PPE to don for other situations should be directed to the Drug Policy
b. When handling body wastes and fluids (e.g., blood, breast milk, feces, saliva, sputum,
sweat, tears, vomit, and urine) workers should wear appropriate PPE for 48 hours
following the last drug administration
c. Inhalation potential is highest when handling crushed tablets, opened capsules, powders,
aerosols and spilled volatile liquids.

Policy Title: Preventing Non-therapeutic Exposure to Hazardous Drugs
Policy Number: 6.1.11

Table 1: PPE Work Requirements

D. Use of Primary Engineering Controls
i. No recommendations in this policy replace/supersede the requirements of the US Pharmacopeia
Chapters on Sterile Products (797) and Hazardous Drugs (800).
ii. Hazardous drugs that require alteration shall be manipulated whenever possible (crushed, opened,
mixed, diluted, compounded or otherwise altered) in a C-PEC in an area that is physically
separated from areas where non-hazardous drugs are prepared, that is under negative pressure,
and has at least 12 air exchanges per hour.
a. C-PECs used for nonsterile compounding do not need to meet the requirements for ISO
Class 5 air quality.
Handling Activity
Drug Risk
Single Pair of
Drug administration of
solid dosage forms
High & Low
YES, if liquid that
could splash or
inhalation risk
YES, if inhalation
YES, if liquid that
could splash
YES, if inhalation
Pharmacy hood
Pharmacy hood
YES, if liquid that
could splash
YES, if liquid that
could splash
Transporting patient
with infusing drug
High & Low
Pharmacy hood
Pharmacy hood
YES, if hood not
YES, if hood not
Cleaning trace materials
or environments
High & Low
YES, if liquid that
could splash
Cleaning spills High & Low
Drug administration
requiring withdraw of
injections from vial or
Pharmacy or clinic
receiving, unpacking and
placing in storage
Pharmacy compounding,
crushing tablets,
opening capsules,
repackaging, weighing
or mixing
Pharmacy dispensing,
counting tablets and
capsules from bulk
containers, drug
Drug administration of
non-solid dosage forms
(Solutions, oral liquids,
creams, ointments, gels,
powers, aerosols)
Handling patient body

Policy Title: Preventing Non-therapeutic Exposure to Hazardous Drugs
Policy Number: 6.1.11

b. C-PECs used for sterile compounding shall have ISO class 5 air qualities.
iii. Non-hazardous drugs prepared in a C-PEC reserved for hazardous drug preparation shall be
handled under the same conditions as a Low Risk hazardous drug (i.e., appropriate labeling, PPE
requirements, and administration). These preparations shall be labeled as:
a. Non-hazardous drug prepared in hazardous handling area – PPE required
E. Spill Prevention
i. Hazardous drugs may not be transported in the pneumatic tube system unless they are intact
tablets or unopened capsules that are individually packaged.
ii. When hazardous drugs present a splash or inhalation risk, the drug must be wrapped as individual
doses in impervious, sealed plastic bags before they are transported.
F. Activity or Departmental Work Practices
i. Administration
b. All chemotherapy is administered according to UW Health clinical policy #6.1.1,
Chemotherapy Processes: Informed Consent, Ordering, Verification, Administration,
Documentation and Patient/Family Education.
c. Whenever possible work should be performed at or below eye level.
d. Special handling for High Risk hazardous drugs
1. A plastic lined disposable pad of sufficient size to provide protection when laying
drugs outside the plastic bag on surfaces, and when administering drugs via
syringes must be used.
2. Whenever possible use sterile gauze pads around tubing and syringe
connections prior to disconnecting drugs. As well, ports should be wiped with
alcohol after disconnection.
e. Liquid suspensions formulated from oral hazardous drugs will be prepared in the
pharmacy and not on the patient care unit.
f. Pharmacists should be consulted before manipulating (crushing or opening) any solid
dosage form to ensure that it is safe to do so.
g. IV administration requirements:
1. All High Risk hazardous drugs will be delivered from the pharmacy with the
primary tubing attached and primed.
A. If the patient is treated on the Clinical Research Unit and occasionally
Pediatrics, the tubing may be primed with drug solution for research
purposes. Tubing primed with drug should be appropriately labeled as
2. All Low Risk hazardous drugs will require the nurse to attach and prime the
tubing with a compatible sterile fluid solution.
3. All administration sets used to deliver hazardous drugs should be disposed of
intact at the end of the infusion. Do not un-spike an empty hazardous drug
bag from the tubing.
A. Back prime 2-3 ml of primary fluid into the empty bag to clear the port of
hazardous drug.
B. Close the roller clamp of the line.
C. Wrap a sterile 2x2 around the connection and remove the tubing from
the primary line.
D. Use the gauze to wipe off the port.
4. Connection sites for IV tubing should be checked to ensure they are tight.
5. Infusion sets and pumps are to be observed for leakage.
6. IV pumps are cleaned between patients:
A. Central Services cleans inpatient pumps with hospital grade
B. Pumps used in the outpatient setting are cleaned by staff with hospital
grade disinfectant.
ii. Operating Room/Sterile Field
a. Personnel located in the non-sterile field should follow the PPE requirements outlined in
section C. depending on the hazardous drug category and the activity performed.
b. Persons located in the sterile field should follow all of the PPE requirements outlined in
section C. depending on the hazardous drug category and activity performed. However
the blue impervious disposable gown and non-latex gloves (two pairs donned over the
gown cuff) will be sterile for personnel in the sterile field.

Policy Title: Preventing Non-therapeutic Exposure to Hazardous Drugs
Policy Number: 6.1.11

iii. Respiratory Therapy
a. A standard operating procedure should be defined by the Respiratory Therapy
Department for each specific hazardous drug administered as an aerosol.
b. A warning should be posted in the designated treatment area during administration.
Nonessential personnel are not allowed to enter the area.
iv. Patient Transport
a. Transport employees should follow the spill prevention procedures in section E when
transporting hazardous drugs or a patient who is receiving a hazardous drug.
b. Transport employees involved with a hazardous drug spill should call the nurse on the
patient unit. While awaiting appropriate clean-up, they should keep bystanders away from
the spill.
v. Laundry
a. All laundry shall be treated as if lightly contaminated with hazardous material. Heavily
contaminated items will be disposed of in the proper waste receptacles, see IV.H.i.
b. The laundering process includes prewash and wash.
vi. Investigational Drugs
a. Per UW Health administrative policy #4.11, Investigational and Study Drug Control all
UWHC clinical drug protocols must be coordinated through the Pharmacy Department’s
Pharmaceutical Research Center (PRC).
b. PRC will prepare an informational drug monograph for all Investigational drugs in which
recommendations for appropriate personal protective requirements will be provided.
c. Research protocols involving drugs, agents, devices and/or procedures and possessing
potential health hazards that are not adequately covered by existing biohazardous or
cytotoxic policies and/or where safety policies do exist but the research novelty, location,
route of administration or employees involved render the standard operating procedures
not applicable or inadequate must be reviewed by and approved by the Research Safety
Committee (RSC) before said research can begin at UWHC. The RSC will define
protocol/agent-specific handling procedures accordingly. Refer to UWHC administrative
policy #12.10, Research Safety Committee Authority and Function.
vii. Pharmacy Department Specific
a. Purchasing:
1. Purchasing of hazardous drugs should be made solely through the Pharmacy
b. Receiving:
1. Exposure control should begin when hazardous drugs enter the facility
recognizing that damaged containers present significant risk of exposure.
2. Damaged packages or shipping cartons shall be considered spills that shall be
reported to the department supervisor and through the defined reporting system
outlined in section G. – Spill Management.
c. Storage:
1. All storage areas and containers, regardless of the drug formulation, shall be
labeled as hazardous to prevent improper handling.
2. Unless the hazardous drugs already exist in their final unit dose or unit-of-use
packaging, they shall be stored separately from non-hazardous inventory to
prevent contamination and personnel exposure.
A. Refrigerated hazardous drugs shall be stored in a dedicated refrigerator
in a dedicated storage room, buffer room, or containment segregated
compounding area (C-SCA).
3. Hazardous drugs shall be stored at or below eye level in containers that minimize
the risk of breakage and leakage. They will not be stored on the floor.
d. Transporting
1. Donning PPE is NOT required when the hazardous drug is in the manufacturer’s
original packaging or in sealed impervious protective bag. Compounded sterile
products will be sealed in drug delivery bags which also indicate hazardous
contents inside.
2. When transporting from the compounding area to an outside healthcare entity
hazardous drugs will be packed in a way that prevents damage, leakage,
contamination or degradation. Appropriate packaging shall also protect
transporting personnel from exposure.

Policy Title: Preventing Non-therapeutic Exposure to Hazardous Drugs
Policy Number: 6.1.11

e. Dispensing dosage forms which do not require alteration
1. Drugs in final unit-dose or unit-of-use packaging that will not be altered require
no further protective packaging unless required by the manufacturer.
f. Compounding dosage forms
1. The Pharmacy Department shall dispense hazardous drugs in the final dose and
form whenever possible.
2. Equipment shall be dedicated for use with hazardous drugs whenever possible
and not interchanged with non-hazardous drug equipment unless it is cleaned
thoroughly between each use.
g. Infusion preparation and priming:
1. For High Risk hazardous drugs, the appropriate IV set should be attached and
primed in the Pharmacy Department under the proper engineering controls as
described in Pharmacy Department procedures for handling sterile products and
hazardous drugs.
A. Unless otherwise specified by area (Clinical Research Unit and
occasionally Pediatrics), IV tubing should be primed with the base
solution before the hazardous drug is added to the compound.
B. After preparation, the outside container must be wiped with a USP
approved cleaning gauze prior to being placed in a sealed delivery bag
viii. Disposal of Drug Waste
a. Hazardous pharmaceutical waste will be disposed of according to UW Health Hazardous
Material and Waste Management Plan.
1. Place all needles and syringes as a single unit into the white needle disposal box
(sharps container), designated for hazardous sharps.
2. Dispose of material used to administer all hazardous drugs in the black bin
labeled “Pharmaceutical Waste". This includes IV bags, syringes, tubing, and all
packaging materials containing oral preparations.
3. Do not leave plastic bags containing hazardous drugs or materials used to
administer hazardous drugs in the patient's room or at the bedside.
4. Unused drug should be returned to the pharmacy.
5. Dispose of PPE and other items potentially contaminated with “trace” amounts of
all hazardous drugs in the yellow bag. This includes plastic lined disposable pad,
gauze, gloves, gown etc.
G. Spill Management
i. Spill kits must be located near each work area where hazardous drugs are stored, prepared or
a. Spill kits are ordered from Central Services.
b. The number of kits available in the work area should be adequate to clean the largest
anticipated spill.
c. Kits must be prominently marked and readily accessible. All personnel should be
educated on the location of the kits.
d. Contents of the kit are defined by the manufacturer.
ii. Spill areas are restricted to personnel who are trained to manage spills and who are wearing the
proper PPE. All necessary PPE is located in the kit.
a. N95 masks provided in manufactured kits should not be worn by employees who have not
been fit tested for that exact size mask. If the exact fit tested N95 mask or a PAPR is not
available, the area should be contained and Facilities and Engineering Services contacted
to manage the spill.
iii. The spill is contained by using the pads or towels provided in the kit. Personnel should work from
the area of least to most contamination.
iv. Contaminated surfaces should be cleaned with detergent (soap and water), then rinsed and dried
three times.
v. For spills on carpet, the area should be contained and Facilities and Engineering Services
contacted to manage the spill.
vi. All waste material must be properly discarded.
vii. Incident reporting should be completed for documentation of spills, exposures and unsafe
conditions related to hazardous materials. See section on reporting spills.
viii. If you do not have the appropriate personal protective equipment or have been adversely affected
by the exposure, follow the below procedures:

Policy Title: Preventing Non-therapeutic Exposure to Hazardous Drugs
Policy Number: 6.1.11

a. If adversely exposed, reference first aid section on the Safety Data Sheet (SDS) online
b. Close the door to the spill location
c. Place towel along the lower part of the doorframe
d. Evacuate nearby occupants
e. Notify your supervisor and contact Facilities and Engineering Services
f. Complete a PSN report
H. Hazardous Drug Exposure Management
i. Garments owned by personnel or patients that become heavily contaminated or soiled should be
removed immediately, rolled up with the wet portion inside, and placed in a clear plastic bag and
discarded in the proper waste receptacles.
ii. Worker or patient owned garments, owned by personnel or patients that may have become lightly
contaminated should be rolled up with wet portion to the inside and placed in normal laundry
a. Items that have been lightly contaminated may be re-used after laundering twice at home.
The first wash should be sequestered from other laundry. The second wash may be
added to other laundry.
b. Items contaminated by body excreta (fluids or solids) would be considered as lightly
iii. Exposed skin:
a. Must be washed immediately 3 times with mild soap and water for a total of 15 minutes.
iv. Eye exposure:
a. Eyes should be flushed with water or normal saline at the nearest eyewash station or sink
for at least 15-20 minutes.
v. Inadvertent needle stick:
a. Safety needles are used to prevent needle sticks.
b. When personnel are exposed, the immediate supervisor is contacted and the Accident
Report Form (UWHC) or the Injury Report Form (UWMF) is completed.
c. Employee Health should be contacted for further evaluation during open hours.
d. Personnel should report to the emergency department if Employee Health is closed.
vi. Minor cuts caused by contaminated glass/sharp objects:
a. The affected area should be immediately washed with soap and water for a total of15
vii. Employees with any exposure should apply first aid as specified. During regular business hours
call Employee Health Services (EHS) for subsequent instruction. When EHS is not open, personnel
should proceed to the Emergency Department).
I. Reporting Spills
i. A Patient Safety Net (PSN) report is completed for reporting and documenting all spills, exposures
and unsafe conditions related to hazardous materials. The report should identify the hazardous
drug, items contaminated, persons exposed if any, actions taken, and person cleaning up the spill.
ii. The pharmacist and attending physician are notified to determine the need to re-administer dose.
iii. When a patient has been exposed in a manner other than as prescribed, the attending physician is
iv. When visitors are exposed the immediate supervisor is contacted and the visitor is directed to the
Emergency Department for further evaluation.
v. When personnel are exposed, the immediate supervisor is contacted and the Accident Report
Form (UWHC) or the Injury Report Form (UWMF) is completed.
J. Medical Surveillance
i. The department manager is responsible for identifying and notifying their employees who will be
mixing, administering or handling hazardous drugs that they are eligible to participate in the
voluntary Hazardous Drug Medical Surveillance Program and directing these employees to the
appropriate resources to participate in the program.
ii. Records of hazardous drug exposure will be available for a minimum of 30 years in accordance
with the Access to Employee Exposure and Medical Records Standard.
iii. Medical records associated with employee exposure will be maintained in their permanent medical
file and will be kept for the duration of employment plus 30 years.
iv. When personnel participate in voluntary health monitoring, Employee Health Services (EHS)
should receive information from the supervisor regarding employee’s job duties, including potential
exposure to hazardous drugs.
v. Medical surveillance shall serve as a check on the effectiveness of current controls to prevent

Policy Title: Preventing Non-therapeutic Exposure to Hazardous Drugs
Policy Number: 6.1.11

a. Employees may participate in voluntary baseline health status monitoring through EHS.
This includes ongoing periodic monitoring throughout employment at the discretion of the
employee. Participation is independent of direct exposure to HD.
b. Department managers are responsible for educating appropriate employees about the
availability of the voluntary medical surveillance program through EHS.
c. A follow-up plan will be developed for workers exposed to HDs or who are experiencing
health changes suggestive of toxicity. Plans are individualized depending on the type and
extent of exposure.
d. EHS may analyze aggregate data generated by the program to detect trends that may be
a signal of health changes related to exposure to HDs.
e. Any evidence of exposure-related disease or health changes should prompt re-evaluation
of primary preventative measures.


Appendix A: UW Health Hazardous Drug List
Appendix B: Hazardous Drug Precaution Sign
Health Facts For You (HFFY): Hazardous Drug Safety in the Hospital and at Home #7286
Accident Report Form (UWHC)
Injury Report Form (UWMF)
Hazardous Drug Medical Surveillance History Form
Hazardous Drug Medical Surveillance Program Guidelines


Author: Pharmacy Systems and Operations Coordinator; Pharmacy Drug Program Analyst
Senior Management Sponsor: SVP/Chief Admin Officer
Reviewers: Pharmacy Drug Program Manager; Director Nursing Quality and Safety; OR Nursing Education
Coordinator - Adult Intraoperative; Manager Employee Health Services; Oncology Clinical Nurse Specialist;
Oncology Nursing Education Specialist; Medical Director UW Clinical Laboratories; Oncology Nurse
Manager; Director of Oncology Services; Safety and EM Officer; Infection Control Practitioner; Director
Environmental Services; Director of Respiratory Care; Patient Transport Supervisor; Pharmacy Manager
Oncology Services; Manager Pharmaceutical Research Center; MD Anesthesiology; Director Employee
Approval committees: Pharmacy & Therapeutics Committee, Medication Safety Subcommittee, Oncology
Practice Committee, Safety Committee, Nursing Executive Council, Nursing Practice Council, UW Health
Clinical Policy Committee
UW Health Clinical Policy Committee Approval: May 15, 2017

UW Health is a cohesive, united and integrated academic medical enterprise comprised of several entities.
This policy applies to facilities and programs operated by the University of Wisconsin Hospitals and Clinics
and the University of Wisconsin Medical Foundation, Inc., and to clinical facilities and programs
administered by the University of Wisconsin School of Medicine and Public Health. Each entity is
responsible for enforcement of this policy in relation to the facilities and programs that it operates.


Peter Newcomer, MD
Chief Clinical Officer

J.Scott McMurray, MD
Chair, UW Health Clinical Policy Committee


A. ASHP Guidelines for Handling Hazardous Drugs: American Society of Health-System Pharmacy, 2006.
B. Chemotherapy Guidelines and Recommendations for Practice - Oncology Nursing Society – Oncology
Nursing Press, Inc., revised 2013.

Policy Title: Preventing Non-therapeutic Exposure to Hazardous Drugs
Policy Number: 6.1.11

C. National Institutes for Occupational Safety and Health. Medical surveillance for Healthcare Workers
Exposed to Hazardous Drugs, 2013.
D. NIOSH List of Antineoplastic and Other Hazardous Drugs in Healthcare Settings, 2016.
E. NIOSH Alert: Preventing Occupational Exposures to Antineoplastic and Other Hazardous Drugs in Health
Care Settings. U.S. Department of Health and Human Services Publication Number 2004-165.
www.cdc.gov/niosh. September 2004.
F. OSHA Technical Manual: Section VI: Health-Care Facilities: Chapter 2: Controlling Occupational Exposure
to Hazardous Drugs. January 1999.
G. OSHA: Safety and Health Topics: Hazardous Drugs: U.S. Department of Lab www.osha.gov
H. Unites States Pharmacopeia (USP) General Chapter <800> Hazardous Drugs – Handling in Healthcare
Settings. (15–Apr–2016; updated 29–Apr–2016)
I. Safe Handling of Hazardous Drugs: Reviewing Standards for Worker Protection. Pharmacy Practice News.
2011. University HealthSystem Consortium (UHC) Consensus Statement: Model Hazardous Drug Safety
Plan for Institutions October 2009; revised 2011.
J. UW Health clinical policy #6.1.1, Chemotherapy Processes: Informed Consent, Ordering, Verification,
Administration, Documentation, and Patient/Family Education
K. UW Health Respiratory Protection Program
L. UW Health clinical policy #4.1.13, Hand Hygiene
M. UW Health Hazardous Material and Waste Management Plan
N. UW Health administrative policy #4.11, Investigational and Study Drug Control
O. UWHC administrative policy #12.10, Research Safety Committee Authority and Function


Version: Revision
Last Full Review: October 2, 2017
Next Revision Due: October 2020
Formerly Known as: Hospital Administrative policy #8.89; MF policy #119.002, Preventing Occupational
Exposure to Hazardous Drugs