Title: HAZARDOUS DRUGS (Non-Chemotherapy)

I.D. Number: 1044
Scope: Saskatoon City Hospital
Royal University Hospital
St. Paul’s Hospital
Any PRINTED version of this document is only accurate up to the date of printing 3-Apr-12. Saskatoon Health Region (SHR) cannot guarantee the currency or accuracy of any printed policy. Always refer to the Policies and Procedures site for the most current versions of documents in effect. SHR accepts no responsibility for use of this material by any person or organization not associated with SHR. No part of this document may be reproduced in any form for publication without permission of SHR.

Hazardous Drugs - include those that exhibit one or more of the following characteristics in humans
or animals:
teratogenic (causing developmental damage to a fetus) have characteristics similar to an existing hazardous drug. Note: For the purpose of this policy, the term “Hazardous Drugs” refers to all hazardous drugs
excluding chemotherapy agents. These hazardous drugs require special handling precautions
during preparation, transport and administration as they may have some risk from occupational
exposure. Refer to Appendix A for list of medications.

Note: For administration of chemotherapy drugs refer to the policies in the Tri-Hospital Nursing Policy
and Procedure Manual:

Chemotherapy Drugs for Cancer Treatment: Administration & Precautions #1065 Chemotherapy Drugs for Non-Cancer Treatment: Administration & Precautions #1180 Chemotherapy Drugs (Oral) for Cancer & Non-Cancer Treatment: Administration & Precautions (# to be determined)

1.1 To safely administer hazardous drugs to patients. 1.2 To provide a safe environment for staff working with hazardous drugs. Policies and Procedures: Hazardous Drugs (Non-Chemo)-Admin & Precautions 2. POLICY

2.1 Registered Nurses (RNs), Graduate Nurses (GNs), Registered Psychiatric Nurses (RPNs) Licensed Practical Nurses (LPNs) and Graduate Practical Nurses (GPNs) may administer hazardous drugs by all routes working within their scopes of practice. 2.2 Pharmacy will identify all hazardous drugs as such on the drug packaging and the Medication Administration Record will identify them as requiring Hazardous Drug Precautions. 2.3 Special precautions for safe handling of hazardous drugs will be observed during their preparation, transport and administration. 2.4 Pharmacy will prepare injectable hazardous drugs, including oral drugs that must be compounded in a biological safety cabinet. 2.4.1 A closed system for injectable hazardous drug administration will be maintained. 2.4.2 The IV bag containing hazardous drug will be spiked and the tubing primed with a neutral solution by pharmacy. Injectable hazardous drugs will be delivered in a sealed transport bag. 2.4.3 If patient is unable to swallow or when administering via a PEG or a nasogastric tube, contact the pharmacist for advice on alternative dose formulations and the physician for a new medical order. Note: To dissolve a tablet or capsule, place the medication in a capped “Dissolve-a-
Dose” tube and add diluent (warm water or saline). Securely attach cap and mix
gently until medication is dissolved. Open the small outer cap and attach an oral
syringe and withdraw the entire contents of the tube. For enteric coated tablets,
contact pharmacy as above.

Note: To crush a dose that can’t be dissolved (i.e. coated tablet), place the tablet(s)
into an oral syringe and replace the plunger. Draw 0.5 – 1 ml of water into the syringe
to ‘wet’ the tablet. Place a cap on the syringe and turn the plunger with a grinding
motion to create a coarse powder. Draw several mls of water into the syringe and let
the medication dissolve for several minutes. Shake periodically. Administer.

2.5 While the patient is receiving hazardous drugs: 2.5.1 Hazardous Drug Precaution labels must be placed on the chart and intravenous 2.5.2 A Hazardous Drug Handling sign must be placed above the patient bed or on the room 2.5.3 A Chemotherapy/Hazardous Drug Spill Kit must be readily available on the unit, when injectable and/or liquid hazardous drugs are administered. 2.6 Appropriate PPE must be worn for the task. See table under 3.1.2. 2.7 All supplies and body waste will be disposed of in the usual manner in the regular garbage Policies and Procedures: Hazardous Drugs (Non-Chemo)-Admin & Precautions 2.8 All linens will be processed in the regular manner.

3.1 Pre-Administration
3.1.1 Ensure that signage/spill kit is available as outlined in 2.5. 3.1.2 Determine the appropriate PPE and supplies required for route of administration. See

: Always follow standard precautions when handling patient body fluid
waste as outlined in Infection Prevention & Control Manual policy # 20-10.

Nitrile Gloves (DOUBLED: 1 pair under gown cuff;
1 pair over gown cuff)
Small SPD SKU # 61428
Medium SPD SKU # 61429
Large SPD SKU # 61430
Eye/Face Protection
Eye Shield/Mask SPD SKU # 83128
Full Face Shield SPD SKU # 46899
Impervious Gown
Main Stores SKU # 123011
Chemotherapy/Hazardous Spill Kit
SPD SKU # 201903
Hazardous Drug Precaution Labels
Hazardous Drug Precautions Sign
Plastic backed absorbent liner
2 x 2 gauze
Alcohol Swabs
Intravenous Infusion Pump
ADULTS: IV Pump Tubing with Clave on
Secondary Port
PEDIATRICS: IV Micro Pump Tubing with Clave on
Secondary Port

Closed Male Connector
Spinning Spiros SPD SKU # 206080 Spiros Sterile Red Cap SPD SKU # 201901 Policies and Procedures: Hazardous Drugs (Non-Chemo)-Admin & Precautions 3.1.4 Explain to the patient and family

potential side effects and complications, and the importance of informing nurses of the same 3.2 Oral Administration
3.3 Subcutaneous/Intramuscular Administration
3.4 Intravenous Administration
3.4.1 Protect work area with a plastic backed absorbent pad 3.4.2 Prime the primary IV tubing with a compatible solution that does not contain any 3.4.3 At the bedside, verify the following information before opening the sealed transport the patient’s identity with patient’s armband and the label on the drug the secondary tubing is securely connected to the IV bag there is absence of moisture within the transport bag (i.e. drug leakage) the red cap is on the end of the tubing to indicate sterility. 3.4.4 Infuse the hazardous drug through the secondary port 3.4.5 When drug administration is complete: flush with 10 mls neutral solution at the secondary port (if administering other drugs) flush primary IV tubing with 25 mls of neutral solution prior to disconnection from patient wipe the port(s) after disconnection with a 2x2 gauze 3.5 Report to the Physician

3.6 Document

drug administration on the Medication Administration record (MAR) site of injection and patient’s tolerance of procedure on the nursing flow sheet (if applicable) patient education on the nurses notes/flowsheet Policies and Procedures: Hazardous Drugs (Non-Chemo)-Admin & Precautions 4. REFERENCES

ASHP, September 2007. Process for Updating the List of Hazardous Drugs for the NIOSH Alert on
Hazardous Drugs.
National Institute for Occupational Safety & Health, 2004. Preventing Occupational Exposure to
Antineoplastic & Other Hazardous Drugs in Health Care Settings. Centers for Disease Control &
Prevention (CDC). www.cdc.gov
Winnipeg Regional Health Authority (WRHA). In-site Pharmacy program.
Policies and Procedures: Hazardous Drugs (Non-Chemo)-Admin & Precautions Appendix A
Hazardous Drugs List
*When a new hazardous medication is added within SHR it will be identified with a
“Hazardous Drug Precaution” label. The list below is only intended to give you an idea as to
the hazardous medications within SHR as of Fall 2010, i.e. this list will not be updated
beyond Fall 2010. If you are not familiar with a particular medication and want to determine
whether or not it is classified as a hazardous medication within SHR, please consult a
Nursing Medication Reference, and contact Pharmacy if further information is required.

Policies and Procedures: Hazardous Drugs (Non-Chemo)-Admin & Precautions Appendix B
Hazardous Drug Handling Label
Hazardous Drugs
Appendix C
Hazardous Drug Handling
1. Affix the Hazardous Drug label on the front of the chart and IV
2. Wash hands well before and after patient contact.
3. Wear 2 pairs of non-sterile nitrile gloves when handling hazardous
4. Wear disposable impervious gowns & eye/face protection if there is a
risk of drug splash.
5. All supplies and body waste will be disposed of in the usual manner in

6. Process all linen in the regular manner.

Source: http://www.saskatoonhealthregion.ca/about_us/documents/Nursing%20Affairs/Hazardous_Drugs_Non-Chemo_Admininstration_and_Precautions-1044.pdf


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