Safety Policy Manual Policy No. 106

Transcription

1 Safety Policy Manual Policy No. 106 Policy: Hazardous Drugs (Including Chemotherapeutic) Page 1 of 11 APPLICATION NYU Langone Medical Center (NYULMC) PURPOSE To protect employees from exposure to hazardous drugs. To ensure all waste containing hazardous drugs is disposed of in accordance with federal, state and local governmental regulations. To comply with OSHA regulations. 1.0 DEFINITIONS POLICY AND GENERAL INFORMATION Hazardous Drugs (HDs) - For the purpose of this policy, HDs are drugs that pose a risk to healthcare providers during preparation, administration, or disposal, and that possess one or more of the following four characteristics: genotoxic carcinogenic teratogenic or known to cause fertility impairment known to exhibit serious organ or other toxic manifestations at low doses in experimental animals or treated patients See Appendix A for a list of commonly used HDs and Appendix B for the NYULMC 2013 Hazardous Medication List Tisch Hospital Main Campus. 2.0 RESPONSIBILITIES 2.1 Environmental Health and Safety (EH&S) is responsible for: developing the policy for the safe handling and disposal of HDs assisting departments in the development of departmental protocols evaluating the effectiveness of the policy managing the HD Waste Disposal Program Revised: September 20, 2013

2 Safety Policy Manual Policy No. 106 Policy: Hazardous Drugs (Including Chemotherapeutic) Page 2 of 11 providing assistance to departments as needed to resolve technical and other issues, such as assistance with training and in the selection of personal protective clothing and equipment 2.2 Departmental Heads, or their designees, are responsible for compliance with the Policy within their departments. Their responsibilities include, but are not limited to: ensuring that all employees who may be exposed to HDs receive an orientation which covers the known material outlined in this policy ensuring appropriate protective equipment and clothing is readily available in each work area and is used in accordance with this policy ensuring all HD containers are properly labeled ensuring that appropriately labeled hazardous waste containers are readily accessible in all areas where HDs are used developing any additional protocols needed to ensure departmental employees are adequately protected 2.3 Employees who work with HDs are responsible for: reading and complying with all applicable sections of this policy attending departmental training sessions notifying their supervisors of exposures, spills or other pertinent problems 3.0 DRUG PREPARATION Reconstitution of HDs is restricted to designated personnel and must be done in a biological safety cabinet (BSC). 3.1 Personal Protective Equipment (PPE) Powder-free nitrile gloves shall be used for preparation of HDs unless the drug manufacturer specifically stipulates that some other glove provides better protection. A double layer of gloves is substantially less permeable and should be used if double-gloving does not interfere with the technique. Because all gloves are to some extent permeable, and their permeability increases with time, they should be changed regularly (hourly is preferable) or immediately if they are torn or punctured. Revised: September 20, 2013

3 Safety Policy Manual Policy No. 106 Policy: Hazardous Drugs (Including Chemotherapeutic) Page 3 of A protective disposable gown made of lint-free low permeability material with a closed front, long sleeves and elastic or knit-closed cuffs, or equivalent protective clothing, shall be worn. The cuffs shall be tucked under the gloves. Gowns and gloves shall not be worn outside the preparation area All gowns, gloves, and other disposable materials that may be contaminated with HDs shall be disposed of in accordance with HD waste disposal procedures (see Section 6.0). 3.2 Preparation Area Warning signs, designating the area as a Hazardous Drug Preparation Area for authorized staff only, shall be posted. Spill procedures shall also be posted. Eating, drinking, smoking, chewing gum, applying cosmetics, and storing food in or near the preparation area are prohibited A Class II BSC shall be used for the preparation of HDs. The blower on the vertical airflow hood shall be on at all times, 24 hours a day, 7 days a week. BSCs shall be certified through the EH&S Certification and Maintenance Program at least annually and any time the cabinet is moved. Contact EH&S for information on certification and maintenance. 3.3 Preparation Equipment HDs shall be prepared in a BSC on a disposable, plastic-backed paper liner. The liner shall be changed after any overt spill and after each work shift All necessary items shall be placed within the BSC before work begins, and all extraneous items shall be kept out of the work area in order to avoid contamination Syringes must always be large enough so that they are never more than three-fourths full. A non-splash disposal collection vessel such as a plastic or metal tray lined with sterile gauze pads shall be at hand to collect excess solution A closable, puncture-resistant, shatter-proof container for disposal of contaminated sharp or breakable materials, including glass drug vials, shall be readily available in each preparation area Sealable plastic bags, such as wire tie or "zip-lock" bags, shall be at hand so that all contaminated materials (other than sharps), including gloves, Revised: September 20, 2013

4 Safety Policy Manual Policy No. 106 Policy: Hazardous Drugs (Including Chemotherapeutic) Page 4 of 11 drug vials and paper liners, can be immediately placed in them. Sealed waste bags shall be discarded in the black "Hazardous Waste" containers (see Section 6.0) The BSC shall be cleaned with 70% alcohol daily, whenever spills occur, and when the cabinet requires service or certification. Decontamination shall consist of surface cleaning with high ph agents, followed by thorough rinsing. Removable work trays, if present, shall be removed, and the back of the work tray and the sump below shall be included in the cleaning. 3.4 Work Practices during Preparation Proper aseptic techniques must be used The following special precautions are necessary for work in a BSC: Manipulations shall not be performed close to the work surface. Unsterilized items, including liners and hands, shall be kept downstream from the work area to prevent contamination of the drug All syringes, IV bags and bottles containing HDs shall be labeled with a distinctive warning label such as "Hazardous Drug -- dispose of properly." Syringes and IV Bags Vials Syringes and IV bags shall be labeled with patient's name and room number, drug name and quantity per total volume, route of administration, date prepared, dose, expiration date, and storage requirements if the drug is not to be administered immediately. Medication vials shall be vented only in a BSC, unless a hydrophobic filter-needle unit or other approved chemo dispensing pin type device is available to eliminate pressure. A sterile gauze shall be wrapped around the needle and vial top when withdrawing solution (employees should take care to avoid needle-sticks during this procedure). The drug shall be withdrawn from the vial while negative pressure is maintained. If this use of negative pressure is considered impossible, a syringe shall be filled with air equal to the volume of drug required, and the solution withdrawn by alternately injecting small amounts of air into the vial and withdrawing equal amounts of liquid until the required volume is withdrawn. The drug shall Revised: September 20, 2013

5 Safety Policy Manual Policy No. 106 Policy: Hazardous Drugs (Including Chemotherapeutic) Page 5 of 11 be cleared from the needle and hub of the syringe before withdrawing, to avoid spraying on withdrawal Ampules Any material remaining in the top of an ampule shall be tapped down into the ampule before it is opened. A sterile gauze pad shall be wrapped around the ampule neck before breaking the top to protect against cuts and to catch aerosolized material Needles To expel air, the needle shall be held vertically with the needle upwards; the syringe shall be tapped to allow air bubbles to rise to the top of the solution, and the air bubbles expelled into sterile gauze, not into the air. If there is no immediate access to HD disposal container, then gauze shall be placed into an appropriately labeled plastic bag Oral agents 4.0 DRUG ADMINISTRATION Unit dose packaging is preferred for oral hazardous drugs. Packaging shall be opened carefully, and touching the tablet or capsule should be avoided. Drugs shall be placed directly into a medicine cup for administration. All waste shall be discarded in the appropriate hazardous waste container. Any manipulation of oral drugs, such as crushing, breaking, or mixing tablets with food or fluids shall be performed in a biologic safety cabinet designed for hazardous drug preparation. 4.1 PPE Employees who administer HDs shall wear nitrile gloves and a gown if there is a potential for exposure. 4.2 Work Practices Hands shall be washed before putting on gloves. Gowns or gloves that become contaminated shall be changed immediately Infusion sets and pumps, which should have Luer-lock fittings, shall be watched for signs of leakage during use. In situations where tubing could leak, a plastic-backed absorbent pad shall be available. Revised: September 20, 2013

6 Safety Policy Manual Policy No. 106 Policy: Hazardous Drugs (Including Chemotherapeutic) Page 6 of 11 Revised: September 20, Where feasible, priming IV sets and expelling air from syringes shall be carried out in a BSC. If this is not feasible, gauze in a plastic bag shall be used as a receptacle. Syringes, IV bottles and bags, and pumps shall be wiped clean of any drug contamination Contaminated materials shall be discarded into a black "Hazardous Waste" container Hands shall be washed after removal of gloves. 5.0 CARING FOR PATIENTS RECEIVING HDs 5.1 PPE and Work Practices Personnel dealing with blood, vomitus, or excreta from patients who have received HDs in the previous 48 hours shall wear exam gloves and phlebotomists disposable gowns, to be discarded after each use into black Hazardous Waste" containers (see Section 6.0) Hands shall be washed after removal of gloves or after contact with the above substances. 5.2 Linen Linen contaminated with HDs, blood, vomitus, or excreta from a patient who has received HDs in the previous 48 hours shall be handled carefully to minimize the potential for aerosolization Building Service personnel shall wear protective gloves when handling contaminated linen in patient care areas Employees who work in the laundry room shall wear protective gloves and gowns when handling contaminated linen. 6.0 WASTE DISPOSAL Refer to NYULMC Safety Policy No. 108b: Drug and Chemical Waste from Patient Care. 7.0 SPILLS 7.1 General Procedures Spills and breakages shall be cleaned up immediately by trained personnel.

7 Safety Policy Manual Policy No. 106 Policy: Hazardous Drugs (Including Chemotherapeutic) Page 7 of Personnel must wear gloves regardless of the size of the spill. In addition, personnel shall wear gowns and eye protection when cleaning up spills EH&S must be contacted to clean up a spill if there is any danger of airborne powder or aerosol being generated. (A HEPA filtered respirator shall be worn during such clean ups, in accordance with Safety Policy No Respiratory Protection. 7.2 Chemotherapy Spills within the Oncology Nursing Areas For spills of chemotherapy drugs within the Oncology Nursing areas, refer to the NYU Hospitals Center Oncology Nursing Service Process Standard (Appendix C) for the required cleanup procedures to follow. 7.3 Clean Up of Small Spills Liquids shall be absorbed using plastic backed pads; powders shall be wiped with wet absorbent gauze. The spill areas shall then be cleaned with a detergent solution and rinsed twice with clean water. An appropriate NIOSH approved respirator shall be used, in accordance with Safety Policy No Respiratory Protection Program, for spills where airborne powder or aerosol has been generated Any broken glass fragments shall be placed in a small cardboard or plastic container and then into a black "Hazardous Waste" container along with all other contaminated waste Contaminated reusable items such as pumps shall be wiped dry at the point of contamination. The equipment shall then be cleaned as per standard protocol. 7.4 Cleanup of Large Spills EH&S must be contacted immediately Access to spill area shall be restricted The spread of the spill shall be limited by gently covering with absorbent sheets or spill-control pads or pillows or, if a powder is involved, with damp cloths or towels. Care shall be taken not to generate aerosols. An appropriate NIOSH approved respirator shall be used, in accordance with NYULMC Safety Policy No. 109: Respiratory Protection Program, for spills where airborne powder or aerosol has been generated. Most hazardous drugs are not volatile; however, this may not be true for all Revised: September 20, 2013

8 Safety Policy Manual Policy No. 106 Policy: Hazardous Drugs (Including Chemotherapeutic) Page 8 of 11 HDs. The volatility of the drug shall be assessed prior to selecting the type of respiratory protection An appropriately labeled hazardous waste container shall be brought to the spill site. After picking up the spill, all contaminated surfaces shall be thoroughly cleaned three times with detergent and water. All contaminated absorbents and other disposable materials shall be discarded into this container Contaminated reusable items shall be placed in a sealed plastic bag for transport to a sink. They shall be carefully washed with detergent by personnel wearing double gloves and other appropriate PPE. 7.5 Spills in BSCs After the above spill clean-up procedures have been followed, decontamination of all interior surfaces may be required. If the HEPA filter of a BSC is contaminated, the unit must be labeled "Do not use -- contaminated", and the filter changed and disposed of by the contractor used to service BSCs. Arrangements for decontamination may be made by contacting EH&S. 7.6 Spill Kits Spill kits shall be kept in or near preparation and administrative areas. Kits are available from EH&S. 8.0 PERSONNEL CONTAMINATION Overt contamination of gloves or gowns, or direct skin or eye contact shall be treated as follows: Immediately remove gloves and/or gown. For skin contact, wash the affected skin area with soap (not a germicidal cleaner) and water. For eye exposure, flush the affected eye with water or saline solution for at least 5 minutes. If contact lenses are in place, they should be removed prior to eye washing and should not be replaced into the eye. Report the incident to a supervisor and report to Employee Health Service or the Emergency Department in accordance with NYULMC Safety Policy No. 101: Employee Occupational Injury/Illness Reporting System. Revised: September 20, 2013

9 Safety Policy Manual Policy No. 106 Policy: Hazardous Drugs (Including Chemotherapeutic) Page 9 of STORAGE AND TRANSPORT 9.1 Storage Areas Access to areas where HDs are stored shall be limited to authorized personnel Storage areas shall be marked with a warning sign Where feasible, HDs shall be stored separately from other drugs Facilities shall be designed to prevent containers from falling or being damaged. 9.2 Receiving Damaged HD Packages Only personnel who have received hazard awareness training are permitted to handle damaged HD packages. Contact EH&S for assistance, if needed Damaged cartons shall only be opened in a BSC by an employee wearing the same protective equipment as is used in preparation (see Section 3.1) Broken containers and contaminated packaging shall be placed in a puncture-resistant receptacle, which shall then be placed in a black Hazardous Waste" container (see Section 6.0). 9.3 In-house Transportation HDs shall be securely capped or sealed and packaged in impervious packing material for transport Personnel involved in transporting HDs must be trained in the hazards of the drugs and the necessary procedures should a spill occur All HDs must be labeled with a warning label and clearly identified as hazardous INFORMATION AND TRAINING 10.1 Material Safety Data Sheets (MSDSs)/Safety Data Sheets (SDSs) The Pharmacy Department shall maintain MSDSs/SDSs for all HDs used at NYULMC MSDSs/SDSs shall be readily available to employees working with HDs. Revised: September 20, 2013

10 Safety Policy Manual Policy No. 106 Policy: Hazardous Drugs (Including Chemotherapeutic) Page 10 of Supervisors shall make MSDSs/SDSs available to employees upon request, in accordance with NYULMC Safety Policy No. 121: Hazard Communication Program Upon request, EH&S may assist with obtaining an MSDS/SDS Training and Personnel Each department shall be responsible for training all departmental employees involved in any aspect of the handling of HDs Training shall include information about the known risks of HDs, relevant techniques and procedures for handling, the proper use of protective equipment and materials, spill procedures, and medical policies Medical staff shall be informed of this policy and of the expectation that they will comply Upon request, EH&S may assist departments with training MEDICAL SURVEILLANCE 11.1 Medical staff potentially exposed to HDs shall be monitored to identify the earliest reversible biologic effects so that the exposure can be reduced or eliminated before the employee sustains irreversible damage. For detection and control of work-related health effects, job specific medical evaluations shall be performed: before job placement periodically during employment (every 1 to 3 years depending on exposure) following acute exposures at the time of job termination or transfer 11.2 Questions about medical surveillance should be directed to Employee Health Services. Revised: September 20, 2013

11 Safety Policy Manual Policy No. 106 Policy: Hazardous Drugs (Including Chemotherapeutic) Page 11 of RELATED SAFETY POLICIES Policy No. 101: Employee Occupational Injury/Illness Reporting System Policy No. 108b: Drug and Chemical Waste from Patient Care Policy No. 109: Respiratory Protection Program Policy No. 121: Hazard Communication Program Appendix A Appendix B Appendix C Sample List of Drugs that Should be Handled as Hazardous NYULMC 2013 Hazardous Medication List - Tisch Hospital Main Campus NYU Hospitals Center Oncology Nursing Service Process Standard Issue date 12/13 Replaces 11/11 Reviewed by J. Goldberg, Environmental Health & Safety P. Hughes, Nursing Education NYUHC Environment of Care Committee Revised: September 20, 2013

12 Revised: September 20, 2013 Safety Policy 106, Appendix A

13 Revised: September 20, 2013 Safety Policy 106, Appendix A

14 Revised: September 20, 2013 Safety Policy 106, Appendix A

15 Revised: September 20, 2013 Safety Policy 106, Appendix A

16 Revised: September 20, 2013 Safety Policy 106, Appendix A

17 Revised: September 20, 2013 Safety Policy 106, Appendix A

18 Safety Policy 106, Appendix B NYULMC 2013 Hazardous Medication List Tisch Hospital Main Campus Anti-Neoplastics Generic Name Brand Name Regulated Dosage Alemtuzumab Inj Campath Inj 30mg/ml Anastrozole Tab Arimidex Tab 1mg Arsenic Trioxide Inj Trisenox Inj 1mg/ml Asparaginase Erwinia Chrysanthemi Inj Erwinaze Inj 10,000 IU/ml Bendamustine Inj Treanda Inj 5mg/ml Bexarotene Tab Targretin 75mg Bicalutamide Tab Casodex Tab 50mg Bleomycin Inj Blenoxane Inj 3unit/ml Bortezomib Inj Velcade Inj 1mg/ml, 2.5mg/ml Brentuximab Inj Adectis 5mg/ml Busulfan Tab Myleran Tab 2mg Busulfan Inj Busulfex Ink 6mg/mL Cabazitaxel Inj Jevtana Inj 60mg/1.5ml Capecitabine Tab Xeloda Tab 500mg Carboplatin Inj Paraplatin Inj 10mg/ml Carfilzomib Inj Kyprolis Inj 2mg/ml Carmustine Implant Gliadel Implant 7.7mg Carmustine Inj BCNU Inj 3.3mg/ml Chlorambucil Tab Leukeran Tab 2mg, 4 mg CisPlatinum Inj Platinol Inj 1mg/ml Cladribine Inj Leustatin Inj 1mg/ml Clofarabine Inj Clolar 1mg/ml Cyclophosphamide Inj Cytoxan Inj 20mg/ml Cyclophosphamide Tab Cytoxan Tab 25mg, 50mg Cytarabine HCl Inj Cytosar Inj 20mg/ml, 100mg/ml Cytarabine Liposome Inj Depocyt Inj 10mg/ml Dacarbazine Inj DTIC Inj 10mg/ml Dactinomycin Inj Actinomycin D Inj 500mcg/ml Dasatinib Tab Sprycel Tab 50mg, 70mg, 100mg Daunorubicin Citrate Liposome Inj Daunoxome Inj 2mg/ml Daunorubicin Inj Cerubidine Inj 5mg/ml Decitabine Inj Dacogen Inj 5mg/ml Page 1 of 5

19 Safety Policy 106, Appendix B NYULMC 2013 Hazardous Medication List Tisch Hospital Main Campus Generic Name Brand Name Regulated Dosage Anti-Neoplastics Degarelix Inj Firmagon Inj 80mg, 120mg Denileukin Deftitox Inj Ontak Inj 150mcg/ml Docetaxel Inj Taxotere Inj 20mg/ml Doxorubicin Liposomal Inj Doxil Inj, Lipodox Inj 2mg/ml Doxorubicin Inj Adriamycin Inj 2mg/ml Doxorubicin powder Inj Adriamycin Inj 20mg Epirubicin Inj Ellence Inj 2mg/ml Eribulin Inj Halaven Inj 0.5mg/ml Erlotinib Tab Tarceva tab 100mg, 150mg Estramustine Cap Emcyt Cap 140mg Etoposide Cap VP-16 Cap 50mg Etoposide Inj VP-16 Inj 20mg/ml Everolimus Tab Afinitor Tab 2.5mg, 5mg Exemestane Tab Aromasin Tab 25mg Floxuridine Inj FUDR Inj 100mcg/ml Fludarabine Inj Fludara Inj 25mg/ml Fluorouracil Inj 5-FU Inj 50mg/mL Flutamide Cap Eulexin Cap 125mg, 250mg Fulvestrant inj Faslodex Inj 250mg Gemcitabine Inj Gemzar Inj 38mg/ml Goserelin Inj Zoladex 3.6mg, 10.8mg Hydroxyurea Cap Hydrea Cap 500 mg 500mg Idarubicin Inj Idamyicin Inj 1mg/mL Ifosfamide Inj Ifex Inj 50mg/ml Imatinib Cap Gleevec Cap 100mg, 400mg Interleukin-2 Inj Proleukin Inj 18 million units/ml Irinotecan HCl Inj Camptosar Inj 20mg/mL Ixabepilone Inj Ixempra Inj 2mg/ml Lenalidomide Tab Revlimid Tab 2.5mg, 10mg, 25mg Letrozole Tab Femara tab 2.5mg 3.75mg, 7.5 mg, Leuprolide Acetate Inj Lupron Depot Inj 11.25mg, 22.5mg, 30mg Page 2 of 5

20 Safety Policy 106, Appendix B NYULMC 2013 Hazardous Medication List Tisch Hospital Main Campus Generic Name Generic Name Generic Name Anti-Neoplastics Lomustine Cap CCNU Cap 10mg, 40mg,100 mg Mechlorethamine Inj Nitrogen Mustard Inj 10mg/ml Melphalan Tab Alkeran Tab 2mg Melphalan Inj Alkeran Tab 5mg/ml Mercaptopurine Tab Purinethol Tab 25mg, 50 mg Methotrexate Inj 25mg/ml Methotrexate Tab 2.5mg Mitomycin Inj Mutamycin Inj 0.5mg/ml Mitotane Tab Lysodren Tab 500mg, 1g, 2.5g Mitoxantrone Inj Novantrone Inj 2mg/mL Nelarabine Inj Arranon Inj 5mg/ml Nilotinib Cap Nilotinib Cap 150mg, 200mg Nilutamide Tab Nilandron Tab 150mg Oxaliplatin Inj Eloxatin Inj 5mg/ml Paclitaxel Inj Taxol Inj 6mg/mL Paclitaxel protein-bound Inj Abraxane Inj 5mg/ml Palatrexate Iinj Folotyn Inj 20mg/ml Pazopanib Tab Votrient Tab 200mg Pegaspargase Inj Oncaspar Inj 750 IU/ml Pemetrexed Inj Alimta Inj 500mg Pentostatin Inj Nipent Inj 2mg/ml Pralatrexate Inj Folotyn Inj 20mg/ml Procarbazine HCL Cap Matulane Cap 50 mg Romidepsin Inj Istodax Inj 10mg Sorafenib Tab Nexavar Tab 200mg Streptozocin Inj Zanosar Inj 1gm Sunitinib Tab Sutent Tab 12.5mg, 25 MG, 50 MG Tamoxifen Tab Nolvadex Tab 10mg Temozolamide Cap Temodar Cap 20mg, 100mg, 250 mg Temozolamide inj Temodar Inj 2.5mg/ml Temsirolimus Inj Torisel Inj 25mg/ml Thalidomide Cap Thalomid Cap 50mg, 100mg Page 3 of 5

21 Safety Policy 106, Appendix B NYULMC 2013 Hazardous Medication List Tisch Hospital Main Campus Generic Name Generic Name Generic Name Anti-Neoplastics Anti-Infectives Immunosuppressants Thioguanine Tab 6-TG Tab 40mg Thiotepa Inj Thioplex Inj 10mg/ml Topotecan Cap Hycamtin Cap 0.25mg, 1mg Topotecan Inj Hycamtin Inj 1mg/ml Tretinoin Cap ATRA 10mg Trastuzumab Emtansine Inj Kadcyla Inj 20mg/ml Tretinoin Cap ATRA Cap 10mg 3.75mg, 11.25mg, Triptorelen Inj Trelstar Inj 22.5mg Vinblastine Sulfate Inj Velban Inj 1mg/mL Vincristine Sulfate Inj Oncovin Inj 1mg/mL Vinorelbine Inj Navelbine Inj 10mg/mL Vorinostat Zolinza Cap 100mg Ziv-Aflibercept Inj Zaltrap Inj 25mg/mL Chloramphenicol Sod Succinate Inj Chloromycetin Inj 100mg/mL Cidofovir Inj Vistide Inj 75mg/mL Entecavir Tab Baraclude Tab 0.5mg, 1mg Ganciclovir Cap Cytovene Cap 250mg Ganciclovir Inj Cytovene Inj 50mg/ml Ribavirin Cap Rebetol Cap 200mg Ribavirin Soln Virazole Soln for Inh 20mg/mL Valganciclovir Tab Valcyte Tab 450mg Valganciclovir Susp Valcyte Susp 50mg/ml Zidovudine Cap Retrovir Cap 100mg Zidovudine Syrup Retrovir Syrup 10mg/mL Azathioprine Inj Imuran Inj 10 mg/ml Azathioprine Tab Imuran Tab 50mg,100mg,150mg Cyclosporine Cap Neoral Cap 25mg, 100mg Cyclosporine Inj Sandimmune Inj 50mg/mL Cyclosporine Oral Soln Sandimmune Oral Soln 100mg/mL Everolimus Tab Zortress Tab 0.25mg, 0.5mg, 0.75mg Page 4 of 5

22 Safety Policy 106, Appendix B NYULMC 2013 Hazardous Medication List Tisch Hospital Main Campus Generic Name Generic Name Generic Name Immunosuppressants Other Mycophenolate Delayed Release Tab Myfortic Tab 180mg, 360mg Mycophenolate Mofetil Cap Cellcept Cap 250mg, 1000mg Mycophenolate Mofetil Inj Cellcept Inj 33.3mg/mL Sirolimus Oral Soln Rapamune Oral Soln 1mg/mL Sirolimus Tab Rapamune Tab 0.5mg, 1mg, 2mg Tacrolimus Cap Prograf Cap 0.5mg 1mg Tacrolimus Inj Prograf Inj 5mg/mL Dutasteride Tab Avodart Tab 0.5mg Finasteride Tab Proscar Tab 5mg Misoprostol Tab Cytotec Tab 100mcg, 200mcg Zoledronic Acid Inj Zometa Inj 4mg/5mL References: NIOSH List of Antineoplastic and Other Hazardous Drugs in Healthcare Settings 2012: Polovich, M. (2011). Safe Handling of Hazardous Drugs. Pittsburgh, PA: Oncology Nursing Society. pp. 34, 37. Developed by: Paul Dantas, Pharm.D., Pharmacy Supervisor Man Yee Merl, Pharm.D., BCOP, Pharmacy Oncology Clinical Coordinator Page 5 of 5

23 Safety Policy 106, Appendix C NYU Hospitals Center Oncology Nursing Service Service Process Standard PROCEDURE FOR: Chemotherapy Spill Kit (Emergency Response Pack), Use of PURPOSE: their unit. To familiarize health care workers with procedures for safely managing chemotherapy spills on SUPPORTIVE DATA: 1. Chemotherapy drugs are administered in a variety of health care settings including the hospital and outpatient areas. Chemotherapy spills are handled following a standard cleanup procedure in all sites. 2. RNs /PCT s who have received instruction in using a spill kit, may clean a chemotherapy spills should the need arise. 3. The spill kit should be used for any spill on non-absorbable surfaces, or for any spill in a bed that involves linen. Double-bag the linen, and dispose of in a hazardous waste container. IF there is pooled or residual chemotherapy remaining on the mattress, this would require the use of a second chemotherapy spill kit. 5. See also Procedure Chemotherapy Disposal PROCEDURE 1. Take out all contents from the Chemotherapy Drug Spill Kit. Immediately post the sign that warns others of the presence of a hazardous spill. 2. Put on the gown, respirator, shoe coverings, safety glasses and both pairs of gloves. KEY POINTS The gloves in the kit may contain latex. If you are allergic to latex, you may substitute two pairs of nitrile gloves. 3. Lay absorbent pads over the spill, being careful not to create a splash. Avoid skin and eye contact with pads. (Do not rub or wipe area with the pad, as this increases the likelihood the pad will decompose and impede clean up.) 4. Detach the scoop from the scraper, and use both to pick up the gel. Place the contaminated gel in the leak proof waste bag. Pads will absorb the liquid and transform it into a gel to assist in disposal. Only use the absorbent pads provided in the spill kit to clean up the spill (Caution: The gel from the pads extremely slippery when wet.) For spills of >500 cc, more than one kit will be needed. If there is any broken glass, use the scoop to pick it up and place in the hazardous waste container in the dirty utility room. 5. Use spill towels, soap and water to pick up any remaining gel. Place towels in the leak proof bag. Seal the bag and place bag in another leak proof bag. For the moment, leave the outer bag open. Afterwards, call Building Services to mop up area using standard disinfectant. (Spill area should be cleaned thoroughly from least contaminated to most contaminated areas, using a detergent followed by clean water and repeat.) Page 1 of 3

24 Safety Policy 106, Appendix C 6. Remove personal protective equipment (PPE) in the following order and place in the unsealed bag: shoe coverings, then outer pair of gloves, followed by safety glasses and gown, and discard. Remove outer gloves before removing glasses so as not to contaminate face with gloves containing chemotherapy. 7. Seal the outer cytotoxic waste disposal bag, then remove inner gloves and discard in hazardous waste container. 8. Dispose of bag in the hazardous waste container in the dirty utility room. Contact Building Services to replace full hazardous waste containers. For spills at the CCC and Hassenfeld, dispose of bag in the hazardous waste container located in the Pharmacy. Page 2 of 3

25 Safety Policy 106, Appendix C REFERENCES: Polovich, M., Whiteford, J., Olsen M.(2009) Chemotherapy and Biotherapy Guidelines and Recommendations for Practice.3 rd Edition. ONS Publishing Division: Pittsburgh, PA. Sage Chemotherapy Drug Spill Kit: Instructions for Use: Crystal Lake, IL: Sage Products Inc.(?) DEVELOPED BY: P. Hughes MA, RN, BC, OCN R. Green, MSN, RN, OCN I. Tudman, MS A. Yood, MA APPROVED BY: Chair, Oncology Nursing Practice Council Senior Director of Nursing, Medical and Oncology Services DATE ISSUED: September 1997 REVIEW MONTH: September Revised September 2003 Revised February 2006 Revised January, 2012 DISTRIBUTION: Patient Care & Nursing Standards Website Page 3 of 3