Transcript Pharmacology and the Nursing Process, 4th ed. Lilley/Harrington

9-Requisition of cytostatic
solutions
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Requisition form:
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Name & gender
Body weight, height and /or BSA
Cytostatic prescribed
Dosage
Type of carrier solution
Volume of the ready-to-administer solution
Required administration time
Signature of doctor, date
Etc….
10-Preparation
A-Work Sheet for the Drug
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Name of cytostatic
Kind and name of finished drug to be used
Types and names of medical devices
Method of proper preparation
Kind of packaging
Information on label
10-Preparation (ct’d)
B-Documentation
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Time at which the preparation started
Batch number of the finished drug used (
cytostatics, solvents,..)
Quantity of cytostatics used
Unusual incidents during the preparation
Name and signature of the person
Etc…
10-Preparation (ct’d)
C-Label
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Name of the pharmacy
Name of the patient
Ward, bed number
Name and quantity of the cytostatic
Type and volume of carrier solution
Method of administration
Required time of administration
Storage conditions
Date of expiry
11- Administration
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General Recommendations
IV Cytotoxic chemotherapy should be
administered by nursing personnel who
have received specialized education and
training, and they should be able to
demonstrate their competency on a
regular basis.
What to Check before
Administration
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Pre-Infusion parameters have to be met
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Required laboratory tests
Echocardiogram
All pre-medications are given
Etc…
What to Check before
Administration
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Review the Physician Order
Read the label on the infusion bag:
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Check for
Check for
order)
Check for
Check for
Check for
Check for
the name of the patient
the name of drug (same as
the dose
the Administration route
the rate of infusion
any special handling conditions
11- Administration
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IV Preparations
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PPE: Gloves, Gowns, Eye protection
Staff should check the blood return in the
catheter to confirm the patency prior to
administration.
On completion of administration, an
appropriate solution should be infused to
flush any remaining cytotoxic out of the
line, then the line may be disconnected.
Personnel Protection
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Use a new pair of gloves for each patient.
Change the gloves if damaged or significant
contamination occurs
Any cuts or scratches on the nurse’s hands
should be covered with waterproof dressings
to prevent infiltration of the site.
Vials containing drugs requiring reconstitution should be
vented to reduce the internal pressure with a venting device
using a 0.22 micron hydrophobic filter or other appropriate
means such as a chemotherapy dispensing pin. This reduces
the probability of spraying and spillage.
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If a chemotherapy dispensing pin is not used, a sterile
Alcohol pad should be carefully placed around the needle
And vial top during withdrawal from the septum.
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The external surfaces contaminated with a drug should
be wiped clean with an alcohol pad prior to transfer or
transport.
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When bubbles are removed from syringes or I.V. tubing,
An alcohol pad should be placed carefully over the tip of
such items in order to collect any of the cytotoxic drugs.
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When opening the glass ampule, wrap it and then
snap it at the break point using an alcohol pad to
reduce the possibility of injury and to contain the
aerosol produced. Use a 5 micron filter needle or
straw when removing the drug solution.
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Syringes and I.V. bottles containing cytotoxic drugs should
be labeled and dated. Before these items leave the preparation
area, an additional label reading, "Caution-chemotherapy,
Dispose of Properly" is recommended.
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6. Designate a workplace for handling hazardous drugs.
7. Have a spill kit and hazardous drug waste
container readily available.
8. Procedure for gowning and gloving: Wash hands, don first pair of
gloves, don gown and face shield, and then don second pair of
gloves. Gloves should extend beyond the elastic or knit cuff of the
gown. Double-gloving requires one glove to be worn under the
cuff of the gown and the second glove over the cuff.
9. Always work below eye level.
10. Visually examine hazardous drug dose while it is still contained
in transport bag.
11. If hazardous drug dose appears intact, remove it from the
transport bag.
12. Place a plastic-backed absorbent pad under the administration
area to absorb leaks and prevent drug contact with the patient’s
skin.
14. Place a gauze pad under the connection at injection ports
during administration to catch leaks.
15. Use the transport bag as a containment bag for materials
contaminated with hazardous drugs, drug containers, and sets.
16. Discard hazardous drug containers with the administration
sets attached; do not remove the set.
17. Wash surfaces that come into contact with hazardous drugs with
detergent, sodium hypochlorite solution, and neutralizer, if
appropriate.
18. Wearing gloves, contain and dispose of materials contaminated
with hazardous drugs and remaining PPE as contaminated waste.
19. Hazardous drug waste container must be
sufficiently large to hold all discarded material,
including PPE.
20. Do not push or force materials contaminated
with hazardous drugs into the hazardous drug
waste container.
21. Carefully remove, contain, and discard gloves.
Wash hands thoroughly after removing gloves.
General Guidelines
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Be careful while giving injections in order to
prevent extravasations.
Be careful during the
connection/disconnection of the bag or
syringe to the administration device.
Never remove the tubing from an IV bag
containing a Cytotoxic drug, and don’t
disconnect the tubing at other points in the
system until the tubing has been flushed well
with a non toxic solution.
11- Administration
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Oral Preparations
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PPE: Gloves, Gowns
Number of tablets to be given should be
shaken from the bottle into a medicine
cup, without skin contact.
Cytotoxic tablets and capsules must never
be crushed, powdered or opened in any
way, for ease of administration.
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Hazardous drugs should be labeled or otherwise identified as
such to prevent improper handling.
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Tablet and capsule forms of hazardous drugs should not be
placed in automated counting machines, which subject them to
stress and may introduce powdered contaminants into the work
area.
1. Double gloves are required, as is a face shield if there is a
potential for spraying, aerosolization, or splashing.
2. Workers should be aware that tablets or capsules may be coated
with a dust of residual hazardous drug that could be inhaled,
absorbed through the skin, ingested, or spread to other locations
and that liquid formulations may be aerosolized or spilled.
3. No crushing or compounding of oral hazardous drugs may be
done in an unprotected environment.
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Hazardous drugs should be dispensed in the final
dose and form whenever possible. Unit-of-use
containers for oral liquids have not been tested for
containment properties. Most exhibit some spillage
during preparation or use. Caution must be exercised
when using these devices.
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Bulk containers of liquid hazardous drugs, as well
as specially packaged commercial hazardous drugs
(e.g., Neoral [manufactured by Novartis]), must be
handled carefully to avoid spills. These containers
should be dispensed and maintained in sealable
plastic bags to contain any inadvertent
contamination.
12- Spill Management
Policies & Procedures:
 To attempt to prevent spills
 To govern cleanup of spills (size,
location,…)
 To define the responsibility of spill
management
12- Spill Management
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A spill kit should be present at the
nursing unit where administration takes
place.
The concerned personnel should be
trained to the use of the kit.
Do not forget to report any accidental
spillage.
Decontamination Set-Spill kit
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Instructions for use
Emergency signs
Single-use overall or gown
Overshoes
Respiratory protection mask
Protective gloves
Disposable clothes
Water and ethanol
Waste containers
Documentation forms
13-Waste Management
Cytotoxic waste is considered to be all those
materials which have come into contact with
cytotoxic drugs during reconstitution and
administration:
 Syringes, needles, transfusion sets…
 Empty or partially used vials
 PPE
 Materials used for clean up
 Air filters
 Expired drugs
13-Waste Management
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Cytotoxic waste must be segregated,
packaged and disposed of in a way that
personnel and environment are not
contaminated.
Cytotoxic waste must be incinerated in
a facility approved by an environmental
protection authority.
‫‪ ‬آلودگی شخص ی‬
‫ً‬
‫‪ ‬فورا دستکشها یا روپوش را در آورده و در ظرف مخصوص زباله های شیمی‬
‫درمانی بیندازید‪.‬‬
‫ً‬
‫‪ ‬فورا پوست آلوده شده را با آب و صابون بشوئید‪.‬‬
‫‪ ‬چشم آلوده شده را به مدت حداقل ‪ 15‬دقیقه زیر شیر آب مخصوص شستشوی‬
‫چشم‪ ،‬نگه داشته‪ ،‬یا با آب یا محلول ایزوتونیک مخصوص شستشوی چشم‬
‫بشوئید‪.‬‬
‫‪ ‬اقدامات پزشکی الزم را انجام دهید‪ .‬پروتکل های اقدامات پزشکی در شرایط‬
‫اورژانس ی باید در مکان های مخصوص و قابل دسترس‪ ،‬نگهداری شوند‪ .‬همچنین‬
‫در صورت استنشاق داروهای خطرآفرین پودری‪ ،‬باید مراقبت های پزشکی الزم را‬
‫انجام دهید‪.‬‬
‫‪‬این حادثه را در گزارش پزشکی فرد مورد نظر ثبت کنید‪.‬‬
Guidelines on hazardous drugs
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American society of health system pharmacists
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1985,1990
2005: guidelines on handling hazardous drugs
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NIOSH (Natl. Institutes of Occupational Safety and Health)
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2004:NIOSH Hazardous Drug Alert
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http://www.ashp.org/bestpractices/new/HD-Prepub-final.pdf
Appendix A: Sample list
http://www.cdc.gov/niosh/docs/2004-165/
ISOPP Standards
International Society of Oncology Pharmacy Practitioners
OSHA (Occupational Safety and Health Administration)
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1986
1995: Controlling Occupational Exposure to Hazardous Drugs
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http://www.osha.gov/dts/osta/otm/otm_vi/otm_vi_2.html
Training on Handling of Hazardous Medications
Training must include at least:
• Use of engineering controls including correct use of closed-system
transfer devices
• Use of PPE
• Drug preparation
• Drug Transport
• Drug administration
• Disposal of hazardous materials
• Management of hazardous drug spills
• Management of acute exposure
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Training on Handling of Hazardous Medications
Education Plan
• Orientation to hazardous chemicals
– Key contacts within the organization
– Location of policies
• Encourage employees to notify their physician of their possible
occupational exposure to hazardous drugs
• Educate employees of signs and symptoms
– Based on the agents
• Acute vs. chronic
– Annual review of critical process and hazardous chemicals
– Plan in place to educate on new chemicals
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American Society of Health-System
Pharmacists Guidelines (2006)
“Until the reproductive risks (or lack thereof) associated
with handling hazardous drugs within a safety program
have been substantiated, staff who are pregnant or
breast-feeding should be allowed to avoid contact with
these drugs. Policies should be in effect that provide
these individuals with alternative tasks or
responsibilities, if they so desire. In general, these
policies should encourage personnel to solicit
recommendations from their personal physicians regarding
the need for restricted duties. In the case of personnel
actively trying to conceive or father a child, a similar
policy should be considered, and a specific time period
(e.g., three months) should be agreed upon. Legal
counsel should be sought when establishing policies.”
MNA Survey: Hazardous
Drug Information Form
2006
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2000 nurses surveyed at 3 facilities
400 responses
87% reported handling/administering
hazardous drugs
Only 54% aware of programs re: safe
handling of hazardous drugs and training
Only 30% read programs
Only 12% had classroom training
Only 6% had hands-on-training
Survey results cont.
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Nurses do not identify many drugs they
administer as hazardous
Continue to handle in same manner
Not aware of changes in controls
70% use personal protective equipment,
likely gloves
Use of face shields, and gowns or lab coats
much less likely
10% do not use any PPE
‫نظارت پزشکی‬
‫‪ ‬تاریخچه و آزمایشات پزشکی اولیه کارکنان‬
‫‪ ‬اطالعات شغلی و تاریخچه پزشکی و بارداری (تولید مثل) افراد‬
‫‪ ‬هنگام استخدام افراد معاینات کامل بالینی باید کامل انجام شده‬
‫و هر ‪ 1-2‬سال تکرار شود‬
‫‪ ‬پس از مورد جدی تماس با داروهای خطرآفرین‬
‫‪ ‬داشتن گزارشاتی از داروهایی که فرد ساخته یا تزریق کرده‬
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No single process has been found to
deactivate all currently available hazardous
drugs. The use of alcohol for disinfecting the
BSC or isolator will not deactivate any
hazardous drugs and may result in the spread
of contamination rather than any actual
cleaning.
The MSDSs for many hazardous drugs
recommend sodium hypochlorite solution
(strong oxidizing agent) as an appropriate
deactivating agent.
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Appropriate preparation of materials used in
compounding before introduction into the Class II BSC
or isolator, including spraying or wiping with 70%
alcohol or appropriate disinfectant, is also necessary
for aseptic compounding.
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The area under the work tray should be cleaned at
least monthly to reduce the contamination level in
the Class II BSC (and in isolators, where appropriate).
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For surface decontamination the use of gauze
moistened with alcohol, sterile water, peroxide, or
sodium hypochlorite solutions may be effective.