Safe Handling of Hazardous Drugs - BC Cancer

1 safe Handling of Hazardous Drugs Module 1 Includes Recommended Procedures and Techniques BC Cancer PHARMACY PRACTICE STANDARDS FOR Hazardous Drugs September 2021 1-2 Table of Contents Section A - safe Handling Principles .. 6 Potential Hazards of Handling Hazardous Drugs .. 6 Hazardous Drug List .. 7 BC Cancer Hazardous Drug Evaluation Criteria .. 7 Medical Surveillance .. 7 Personal Exposure Records .. 8 Work Re-Assignment .. 8 Section B - Decontaminating, Cleaning, Deactivating, Disinfecting, and Sporicidals .. 9 General .. 9 Decontamination .. 9 Cleaning .. 9 Deactivation.

2 9 Disinfection ..10 Sporicidals ..10 Odor Limiting and Odor Containment Strategies ..10 Section C - Controlled Area .. 10 International Standards Organization (ISO) Classifications .. 10 Room Specifications .. 11 HEPA Filter ..11 Signage ..11 Hazardous Drug Clean Room ..11 Hazardous Drug Anteroom ..12 Hazardous Drug Storage Room ..12 Other Rooms in the Controlled Specifications of the Controlled Area ..13 Summary of Engineering Control Requirements for Hazardous Drug Sterile Product Preparation and Storage Areas .. 15 Equipment and Furniture .. 16 Containment Primary Engineering Control.

3 16 Class I Class II BSC ..17 HEPA Filter ..18 Airflow ..19 Ultraviolet Lights ..19 Viewing Window ..20 Location ..20 Monitoring ..20 Testing and Certifying Biological Safety Cabinets ..21 Replacing HEPA Filters ..21 Turning off a Containment Primary Engineering Control (C-PEC) ..22 Decontaminating, Cleaning, and Disinfecting Interior Surfaces of the Containment Primary Engineering Control (C-PEC) ..22 Communication System ..24 Carts ..25 BC Cancer PHARMACY PRACTICE STANDARDS FOR Hazardous Drugs September 2021 1-3 Chairs ..25 Decontaminating, Cleaning, Deactivating, and Disinfecting Surfaces in the Controlled Area.

4 25 Table 1: Daily Decontaminating, Cleaning, Disinfecting, and Sporicidal Use ..26 Table 2: Weekly Decontaminating, Cleaning, Disinfecting, and Sporicidal Use ..26 Table 3: Monthly Decontaminating, Cleaning, Disinfecting, and Sporicidal Section D - Protective Measures .. 27 General .. 27 Personal Protective Equipment (PPE) and Clean Room Garb .. 28 Scrubs ..29 Footwear ..29 Shoe Covers ..29 Hair Covers ..30 Medical Masks ..30 Respirators ..31 N95 Respirator ..31 Chemical Cartridge Respirator ..31 Powered Air Purifying Respirator (PAPR) ..31 Chemotherapy Gowns ..32 Isolation Gowns.

5 33 Chemotherapy Gloves ..34 Eye Table 4: Summary of Process for Donning Personal Protective Equipment and Clean Room Garb (For controlled area with anteroom and HD clean room only) ..37 Table 5: Summary of Process for Donning Personal Protective Equipment and Clean Room Garb (For controlled area with other rooms in addition to anteroom and HD clean room) ..38 Hand Hygiene .. 39 Hand Hygiene Agents ..39 Alcohol-Based Hand Rub ..39 Hand Washing After Handling Hazardous Drugs ..39 Compounding personnel ..39 Table 6: Hand Hygiene for Sterile Compounding Personnel ..40 Non-compounding personnel.

6 40 Nails and Nail Polish ..40 Safety 41 Eyewash Stations ..41 Sink Mounted ..41 Hand Held Portable ..42 Emergency Showers ..42 Safety Stations Maintenance ..42 Section E - Supplies and Devices .. 43 Supplies .. 43 Wipes/Towels ..43 Preparation Pad / Sterile Drape ..43 Sterile Alcohol Swabs ..43 Devices .. 43 Syringes ..44 Syringe Tip Caps ..45 BC Cancer PHARMACY PRACTICE STANDARDS FOR Hazardous Drugs September 2021 1-4 Needles ..45 Needle Caps ..46 Needle Cap Holders ..46 Seals ..46 Filters ..46 Filter Needles ..47 Filter Discs ..47 Filter Venting Devices.

7 47 Chemotherapy Dispensing Pins ..48 Chemotherapy Vents ..49 Syringe Fluid Dispensing Connectors/Syringe Tip Connectors ..50 NON- Hazardous Solution Dispensing Pins/Universal Spikes ..50 Solution/Intravenous Administration Sets ..50 Buretrols ..50 Winged Infusion Sets ..50 Closed System Drug Transfer Devices ..51 ChemoLock Vial Spike ..51 ChemoLock Injector ..51 ChemoLock Bag Spike ..52 ChemoLock Port ..52 ChemoLock Syringe Transfer Set with MicroClave and ChemoLock Port ..52 ChemoLock Syringe Transfer Set with Double ChemoLock Ports ..52 ChemoLock Secondary Set with Drip Chamber.

8 52 Containers .. 53 Ampoules ..53 Polyvinyl Chloride (PVC) Bags ..54 Non-Di(2-ethylhexyl)phthalate (Non-DEHP) Bags ..54 Empty Sterile Infusion Bags ..55 Evacuated Containers ..55 Ambulatory Drug Delivery Infusion Devices .. 55 Elastomeric Infusion Devices ..55 Medication Delivery via Infusor ..56 Infusor Flow Infusor Volume Capacities and Fixed Flow Rates ..57 Hazardous Drug Medication Infusion Device Labels ..57 Computerized Ambulatory Drug Delivery (CADD ) Pump and Medication Cassette Reservoir57 Section F - Aseptic and Protective Processes .. 58 Operational Standards for Sterile Hazardous Drug Preparation.

9 58 Personnel Hygiene in the Controlled Area ..58 Personal Protective Equipment and Clean Room Garb in the Controlled Area ..59 Containment Primary Engineering Control (C-PEC) ..60 General Procedures ..61 Removing Products from the Containment Primary Engineering Control (C-PEC) ..62 Warning Labels ..63 Exiting the Clean Room ..63 Aseptic/Protective Routines .. 64 F. Critical Sites ..64 First Air ..65 Disinfecting Critical Sites ..65 Coring ..65 Safely Capping Needles Used With Hazardous Drug ..66 BC Cancer PHARMACY PRACTICE STANDARDS FOR Hazardous Drugs September 2021 1-5 safe Handling Aseptic Techniques.

10 66 Transfer of Hazardous Drug Solution from a Syringe ..66 Removal of Bubbles/Air from a Syringe ..66 Attaching and Priming Solution / Secondary Administration Sets ..67 Withdrawal of Excess Solution from an Infusion Solution Bag ..67 Section G - Clean Up and Waste Disposal .. 67 Containment Primary Engineering Control (C-PEC) Waste Cleanup .. 67 Hazardous Waste Disposal .. 67 Section H - safe Handling of Oral, Topical and Pre-Packaged Hazardous Drug Dosage Forms .. 68 Oral Preparations .. 69 Topical Preparations .. 69 Pre-filled Syringes .. 69 Section I - Hazardous Drug Spills.