Implementation of a safety program for handling hazardous drugs in a community hospital

Purpose. The implementation of a safety program for handling hazardous drugs in a community hospital is described. Summary. A committee of representatives of the departments of pharmacy, nursing, human resources, safety, radiology, performance improvement, employee health, and environmental services and members of the hospital administration was formed to formally address the management of hazardous drugs in a community, not-for-profit, adult hospital in Omaha, Nebraska. Published guidelines and regulations were reviewed to determine the hospital's compliance with the handling of hazardous drugs. A knowledge deficit regarding the risk and severity of occupational exposure to hazardous drugs was identified. A formal education plan was immediately implemented providing inservice education to all staff who may come into contact with hazardous drugs. Each drug was electronically tagged in the hospital computer system. The nitrile gloves used in the pharmacy were switched to a brand tested for resistance to chemotherapy drug permeation. The use of personal protective equipment for all health care workers who may come into contact with hazardous drugs was also instituted. Waste stream management was addressed, and a new waste stream was identifed and implemented to address chemicals regulated by the Resource Conservation Recovery Act. Nursing, pharmacy, and housekeeping personnel were extensively educated on the different waste streams and the importance of segregating waste at the point of use. All gloves for housekeeping and laundry service staff were replaced with hazardous-drug-rated nitrile gloves. Conclusion. A gap analysis allowed a multidisciplinary team to establish a safety program for managing hazardous drugs in a community hospital.