Changes to how healthcare staff handle and administer chemotherapy has changed over the past several years as new guidelines come out.
However; even though new guidelines are being put out by organizations, like USP <800> and OSHA, our hospital policies and nursing practice often lag behind and do not always reflect these changes.
When we surveyed nurses who took our APHON Pediatric Chemotherapy Biotherapy Provider Course, one big discrepancy we kept seeing was: inconsistent chemotherapy safe handling practices.
Inconsistent safe handling practices increases a nurses’s risk for developing acute symptoms like headache, coughing, nausea, and nose-burning sensation as well as long term side effects such as nose burning sensation, infertility and developing cancer (1).
Inconsistent practices can increase environmental contamination exposing not only staff, but patients, family, and visitors. One study showed 60% of surfaces in different outpatient clinics tested positive for numerous chemotherapy agents including 5-FU, platinum, ifosfamide, and methotrexate (2).
By engaging in conversation with the nurses who take our course, we have identified 3 common safe handling mistakes that significantly increase chemotherapy contamination and acute chemotherapy exposure.
1. Not checking chemotherapy in a designated place.
Chemotherapy residue has been found in various areas in the hospital including (3):
Countertops
Door handles
Medication refrigerator shelves
Patient infusion chairs
IV Infusion pump keypads
Checkout desk area
Elevator buttons outside of patient care area
Nursing computer stations where nurses chart, nursing break rooms where nurses eat, and even on elevator buttons outside the unit (insert link).
Acute exposure from chemotherapy residue has significant health consequences and puts patients, family, visitors, and healthcare staff at increased risks for negative health effects.
Before administering chemotherapy to the patient, the chemotherapy drug must be checked to the treatment protocol by two nurses. When chemotherapy is checked in designated areas to avoid department contamination and nurse exposure.
Assigning a designated area for chemotherapy to be checked by nurses can be a helpful strategy to control contamination.
However, for some smaller units like infusion clinics or private practice clinics, having a designated area for chemotherapy checking may not be feasible. Using a disposable plastic-backed chemo mat under chemotherapy ziploc bags and IV tubing can minimize contamination (4).
2. Double flushing toilets
Chemotherapy can be found in a patient’s urine up to 2-7 days after administration depending on the medication’s half life (5).
Patients who receive chemotherapy are instructed to double flush after using the bathroom at home to ensure all hazardous bodily waste was effectively flushed down the toilet.
However, hospitals have high-pressurized toilets, in which double flushing might increase aerosolization of hazardous waste (6). Furthermore, hospital toilets do not have a lid which further increases the risk of aerosolization.
Nurses and nursing assistants who handle hazardous urine report “holding their breath and running out of the bathroom,” after flushing the patient’s urine. This common practice is highly unsafe and offers no protection to staff.
To protect staff from hazardous bodily fluid exposure, policy on handling hazardous waste must include:
Personal protective equipment to be worn
How to safely flush toilet to decrease aerosolization risk
How to safely dispose of bodily waste
How long is a patient’s bodily fluid hazardous
Labeling of used disposable urinals and hats as hazardous
Having a written policy and communicating it with your nursing and certified nursing assistant staff is crucial in reducing your staff’s exposure to hazardous waste.
3. 2 Nurse Dependent Checks
According to the Institute of Safe Medical Practices (ISMP), a high alert medication is a medication that can pose significant harm to the patient if administered incorrectly (7).
High alert medications, like chemotherapy, have specific safeguarding measures to prevent errors.
One safeguard measure for chemotherapy administration is that chemotherapy needs to be checked independently by two chemotherapy/biotherapy trained nurses. For example, one nurse independently checks 2 patient identifiers, calculates the patient’s body surface area, calculates the dose, and verifies their calculation with the treatment protocol. A second nurse does a second independent check of the same criteria and they discuss any discrepancies. This process is called a 2 Nurse Independent Check and it greatly reduces errors for high alert medications (ISMP).
However, some nurses do a 2 Nurse Dependent Check, where 2 nurses check the doses and parameters together, instead of separately. This 2 nurse dependent check can greatly increase the risk of errors and bias when administering a high alert medication like chemotherapy putting a patient at harm (ISMP).
Ensuring that your staff is handling chemotherapy and hazardous waste safely provides significant benefits to your department:
Decrease environmental chemotherapy residue contamination
Decreased OSHA non-compliance fines
Decrease patient, family, and staff exposure to hazardous drugs
Decreased staff sick calls and worker's compensation
Safer work environment
Questions to Consider For Your Organization:
Where do you commonly see nurses check and handle chemotherapy?
How do your nurses and certified nursing assistants handle urine for patients undergoing chemotherapy?
Are two nurses performing an independent check of chemotherapy?
What systems do you have in place to assess that chemotherapy is consistently being handled safely?
1. He B, Mendelsohn-Victor K, McCullagh MC, Friese CR. Personal Protective Equipment Use and Hazardous Drug Spills Among Ambulatory Oncology Nurses. Oncol Nurs Forum. 2017 Jan 6;44(1):60-65. doi: 10.1188/17.ONF.60-65. PMID: 28067030; PMCID: PMC5225785.
2. Kopp B, Schierl R, Nowak D. Evaluation of working practices and surface contamination with antineoplastic drugs in outpatient oncology health care settings. Int Arch Occup Environ Health. 2013 Jan;86(1):47-55. doi: 10.1007/s00420-012-0742-z. Epub 2012 Feb 5. PMID: 22311009.
3. Connor TH, DeBord DG, Pretty JR, Oliver MS, Roth TS, Lees PS, Krieg EF Jr, Rogers B, Escalante CP, Toennis CA, Clark JC, Johnson BC, McDiarmid MA. Evaluation of antineoplastic drug exposure of health care workers at three university-based US cancer centers. J Occup Environ Med. 2010 Oct;52(10):1019-27. doi: 10.1097/JOM.0b013e3181f72b63. PMID: 20881620.
4. Easty AC, Coakley N, Cheng R, Cividino M, Savage P, Tozer R, White RE. Safe handling of cytotoxics: guideline recommendations. Curr Oncol. 2015 Feb;22(1):e27-37. doi: 10.3747/co.21.2151. PMID: 25684994; PMCID: PMC4324350.
5. Safe Handling of Chemotherapy Waste Material. https://hillman.upmc.com/patients/community-support/education/miscellaneous/chemotherapy-waste
6. Safe Handling Q&A Toilet Flushing. https://www.ons.org/sites/default/files/2020-03/ONS_HOPA_ToiletFlushing.pdf
7. Independent Double Checks: Worth the Effort if Used Judiciously and Properly. https://www.ismp.org/resources/independent-double-checks-worth-effort-if-used-judiciously-and-properly
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