CENTRAL IOWA HEALTHCARE Marshalltown, Iowa PHARMACY POLICY AND PROCEDURE

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Bertha Stevens
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1 CENTRAL IOWA HEALTHCARE Marshalltown, Iowa PHARMACY POLICY AND PROCEDURE Policy #: MM Subject: High Alert and Hazardous Medications (including pharmaceutical waste management) Purpose: The hospital safely manages high alert and hazardous medications Procedure: 1. The hospital identifies, in writing, its high-alert and hazardous medications. a. See Appendix A - High Alert Medications (ISMP) b. See Appendix B - Safety/ Health Hazardous Medications (NIOSH) c. See Appendix C - Environmentally Hazardous/ Dangerous Medications (Stericycle) 2. The hospital has a process for managing high-alert and hazardous medications. a. High Alert Medications i. All high alert medications are identified with a high alert sticker, placed by pharmacy ii. Key safety strategies for safeguarding high alert medications are implemented (ISMP) Table I b. Hazardous Medications i. All formulary drugs have an MSDS sheet available via the facility's intranet (pharmacy is responsible) 1. Identifies Health, Fire, Reactivity and Environmental hazards ii. iii. All Antineoplastic and Other "Safety/Health" Hazardous Drugs are identified by a Hazardous Drug sticker, placed by pharmacy (NIOSH) All "Environmentally Hazardous/Dangerous" drugs have stickers that characterize proper disposal, placed by pharmacy (Stericycle) 1. Compatible Hazardous Rx Waste a. Black Circle Sticker (BKC) = BLACK Container i. Ex. Insulin, trace elements, clindamycin, silvadene b. Black Circle with P Sticker (PBKC) = BLACK P Container i. Ex. Coumadin (and packaging), nicotine (and packaging) 2. Incompatible Hazardous Rx Waste a. Black Circle with Orange Exclamation Sticker (SP, SPC, SPO, SPLP) = BLACK EXCLAMATION Container i. Ex. Aerosols inhalers with canister, silver nitrate 3. Bulk and Trace Chemotherapy Rx Waste a. Black Circle Sticker (Chemo) = BLACK CHEMO Container i. Ex. IV s/syringes/vials with residual chemo agents, chemo spill cleanup debris b. Black Circle Sticker (Chemo) = YELLOW CHEMO Container i. Ex. Empty iv s/syringes/vials/tubing, gowns/wipes/ gloves/ppe

The hospital identifies, in writing, its high-alert and hazardous medications. a. See Appendix A - High Alert Medications (ISMP) b. See Appendix B - Safety/ Health Hazardous Medications (NIOSH) c.

2 4. Hazardous and Infectious Rx Waste a. Purple Circle Sticker = PURPLE Container i. NA c. Non-Hazardous Medications i. All Non-Hazardous Drugs do not have stickers 1. Non-Hazardous Rx Waste a. No Sticker = BLUE Container i. Ex. Antibiotics, lidocaine, Marcaine, heparin, contrast 2. Sewerable Rx Waste a. No Sticker = SINK (drug) i. Ex. Plain iv solutions, solutions containing additives (potassium chloride, potassium phosphate, sodium phosphate, calcium, sodium bicarbonate) 3. Controlled Substances a. No Sticker = SINK/TOILET/CACTUS (drug) and BLUE container (empty container) i. Ex. ALL CII-CV substances (witness and waste) 4. Sharps a. Needles and empty ampoules 5. Regular Trash a. Empty non-hazardous sewerable waste bags/tubing, boxes, packaging d. The Environmental Services Director has the overall responsibility for the Hazardous Waste Management Program (Stericycle) e. Personal Protective Equiment and Engineering Controls are followed when working with hazardous drugs (NIOSH) Table II. 3. The hospital implements its process for managing high-alert and hazardous medications. 4. For hospitals that use Joint Commission accreditation for deemed status purposes: The hospital reports abuses and losses of controlled substances, in accordance with law and regulation, to the individual responsible for the pharmacy department or service and, as appropriate, to the chief executive. a. All abuses/ losses will be reported to the pharmacy director and, as appropriate, to the chief executive officer (CEO) b. Iowa registrants must complete and submit the DEA Form 106 "Report of Theft or Loss of Controlled Substances" to the Board within 14 days of discovery of theft or loss c. The registrant will maintain a copy of the report for two years Additional Information: *High-alert medications - those medications that bear a heightened risk of causing significant patient harm when they are used in error (ISMP) *Hazardous drugs - include those drugs that exhibit one or more of the following six characteristics in humans or animals: carcinogenicity, teratogenicity or other developmental toxicity, reproductive toxicity, organ toxicity at low doses, genotoxicity, structure and toxicity profiles of new drugs that mimic existing drugs determined hazardous by the above criteria (NIOSH) Closing Banner: Originated by: Pharmacy Department Effective date: 4/12

Controlled Substances a. No Sticker = SINK/TOILET/CACTUS (drug) and BLUE container (empty container) i. Ex. ALL CII-CV substances (witness and waste) 4. Sharps a. Needles and empty ampoules 5.

Pharmaceutical Waste Management Program St. Joseph Mercy Oakland. Pharmacy/Patient Care

Pharmaceutical Waste Management Program St. Joseph Mercy Oakland Pharmacy/Patient Care Objectives Understand the background and regulatory requirements Identify pharmaceutical waste and how to dispose