5:00 GUIDELINES FOR ORDERING, PREPARATION, DISPENSING, HANDLING, AND DISPOSAL OF

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1 5:00 GUIDELINES FOR ORDERING, PREPARATION, DISPENSING, HANDLING AND DISPOSAL OF INTRAVENOUS AND HAZARDOUS DRUGS 5:01 Goals 5:02 Definitions 5:03 Hazardous Medication List 5:04 Personnel Requirements, Training and Duty Assignment 5:05 Receiving, Storage, and Distribution 5:06 Review of Chemotherapy Orders 5:07 Outpatient Prescriptions for Chemotherapy that are Administered outside MDACC 5:08 Dispensing Non-Injectable Hazardous Drugs 5:09 Patient Education 5:10 Hazardous Drug Intravenous Admixtures Guidelines 5:11 Preparation of Hazardous Drugs 5:12 Intrathecal Chemotherapy Preparation 5.13 Vinca Alkaloids Dispensing Requirement 5:14 Viral Products 5:15 Disposal of Hazardous Drug Waste 5:16 Management of Accidental Contact with Hazardous Drugs 5:17 Management of Pharmacy Hazardous Drug (Chemotherapy) Spills 5:00 GUIDELINES FOR ORDERING, PREPARATION, DISPENSING, HANDLING, AND DISPOSAL OF INTRAVENOUS AND HAZARDOUS DRUGS 5:01 Goals Address safe handling methods for controlling, preparing, containing, administering, and disposing of hazardous drugs. Protect and secure hazardous drugs (packages, vials, etc). Contain hazardous drugs when they are manipulated (i.e., dissolved, transferred, administered, or discarded.) Provide engineering and procedural controls, personal protective equipment, and employee training as protective measures for pharmacy personnel exposure to hazardous drugs. Guidelines shall be in accordance with leading guidance sources such as ASHP Guidelines on Handling Hazardous Drugs, NIOSH, RCRA, USP 797, and all applicable federal and state laws. See Glossary. 5:02 Definitions Hazardous drugs: Any drugs identified by at least one of the following six criteria: carcinogenicity, teratogenicity or developmental toxicity, reproductive toxicity in humans, organ toxicity at low doses in humans or animals, genotoxicity, and new drugs that mimic existing hazardous drugs in structure or toxicity (ASHP Guidelines on Handling Hazardous Drugs; 2006). Hazardous waste: Any waste that is an RCRA-listed hazardous waste or that meets an RCRA characteristic of ignigtability, corrosivity, reactivity, or toxicity. 5:03 Hazardous Medication List The Hazardous Medication Drug List for M. D. Anderson Cancer Center includes: Chemotherapeutic agents Investigational drugs Other medications identified by the organization as based on agents listed as hazardous by NIOSH.

2 5:04 Personnel Requirements, Training and Duty Assignment All workforce staff must comply with policies and procedures for the safe handling of hazardous drugs Engineering and procedural controls, personal protective equipment, employee training, and annual handling and preparation reviews are used to protect all workers from exposure to hazardous drugs. Pharmacy does not grant employee requests not to work with hazardous drugs. Employees that believe they qualify for an accommodation under the Americans With Disabilties Act should contact 5-myHR. 5:04.01 Personnel Training and Documentation The Division of Pharmacy provides information and training for all pharmacy personnel with respect to the safe handling of hazardous drugs. Such training is conducted as a component of new employee orientation for preparer(s) and handler(s) of hazardous drugs. Such instruction and training of the handling of hazardous drugs is documented. 5:04.02 Levels of Instruction There are three levels of instruction of safe handling of hazardous drugs for employees in the Division of Pharmacy, as follows: Pharmacy Personnel who handle and prepare hazardous drugs Pharmacy Personnel who handle hazardous drugs Other Pharmacy Personnel Non-handlers (do not handle or prepare hazardous drugs) 5:05 Receiving, Storage, and Distribution Access to areas where hazardous drugs are stored and prepared are limited to authorized staff Appropriate personal protective equipment must be worn by staff conducting hazardous drug receiving, storage, and distribution functions. Damaged products such as containers, cartons, etc. must be handled according to hazardous drugs spill procedures. Hazardous drugs shall be stored separately from other inventory in a manner to prevent contamination and personnel exposure (separate shelves, separate bins designed to prevent breakage, leakage, etc). All hazardous drugs shall be identified to personnel handling the drugs by using methods such as labeling hazardous drugs bins, shelves, or areas as hazardous drugs. Labeling should be distinct such as use of the universal chemotherapy sticker to identify hazardous drugs and substances. Before leaving the pharmacy all hazardous drug doses must be labeled in a manner which distinguishes them from other drugs (i.e. use of chemo or investigational drug auxiliary labels). Hazardous drugs may be distributed or dispensed via the pneumatic tube system(s) or ETV system only when properly packaged. All hazardous drugs must be enclosed in sealed zip/lock bags and properly protected from breakage. Hazardous drugs may be transported/ delivered only by authorized staff using packaging methods that prevent breakage and leakage from drug containers.

3 5:06 Review of Chemotherapy Orders All medication orders, related medication profiles, and prescriptions are reviewed by the pharmacist for completeness and for potential interactions, duplications or compatibilities prior to preparation and dispensing of drugs for administration to a patient. Verification parameters include: o Patient name and medication record number o Patient s allergies o Height, weight and BSA o Route of administration o Start date and frequency o Verification of drug and dosage o If consent is not properly documented, contact the prescribing physician and document on the order that consent was obtained from the patient and was documented by the prescribing physician o Verify labs as indication on the order o Drug interactions o Attending Physician Signature and ID number Two pharmacists will verify dose calculations 5:07 Outpatient Prescriptions for Chemotherapy that are Administered Outside of MDACC An attending physician must sign outpatient chemotherapy prescriptions. The outpatient prescription must follow the standards of the institutional chemotherapy orders. Faxed chemotherapy orders for outpatient prescriptions will not be accepted Outpatient Clinic Pharmacy personnel handling non-injectable chemotherapy should use appropriate Personal Protection equipment (PPE) Up to a 30 day supply can be dispensed per prescription 5:08 Dispensing Non Injectable Hazardous Drugs Pharmacists shall wear two pairs of powder free, disposable gloves (e.g. nitrile) while dispensing oral dosage forms. Hazardous drugs shall not be placed in automatic counters. Stress by automated counters on the tablets or capsules may introduce powdered contaminants into the work area. Dispensing of hazardous drugs must be completed carefully, and clean equipment dedicated for use with these drugs should be used. Equipment should be cleaned with water saturated gauze, then detergent, and then rinsed. Dispensing trays shall be cleaned before and after counting oral dosage forms. Designated counting trays for hazardous drugs are available. Compounding of hazardous drugs (crushing, dissolving, preparing ointment, etc) should occur in a Biological Safety Cabinet. Preparer(s) must use appropriate personal protective measures (gowns, gloves, etc.). All patient prescriptions for hazardous drugs will be identified with the universal chemotherapy sticker or auxiliary label instructing the patient to use "Caution Chemotherapy". Disposal: Residual hazardous drugs, gloves, gauze, cotton, bottles and any other waste generated in the dispensing of hazardous drugs shall be disposed of in hazardous waste disposal drums.

4 5:09 Patient Education When patients or their care providers will be responsible for manipulating hazardous drugs, they will receive patient education regarding the handling of drugs. See Institutional Policy # CLN0973, Chemotherapy Administration: Intravenous, Subcutaneous, Intramuscular, Oral, Topical) 5:10 Hazardous Drug Intravenous Admixture Guidelines Most hazardous drugs are administered to patients by the intravenous route. Therefore, intravenous admixtures must be prepared using strict aseptic technique procedures. Additional precautions must be taken to prevent undue exposure of personnel and the environment to these agents. Strict adherence to aseptic techniques and preparation of hazardous drug admixtures using special procedures and protective equipment in designated work areas are essential for preparing and providing sterile products safely. 5:10.01 Areas for Hazardous Drug Preparation/ Biological Safety Cabinets (BSCs) The areas for the preparation of hazardous drugs are restricted to authorized personnel trained in preparation and handling requirements. Hazardous drugs shall be prepared in Class II, ISO Class 5 BSCs which shall be located in ISO Class 7 preparation areas. IV preparation areas in which chemotherapy drugs are prepared are to be negative in air pressure to adjacent rooms. Portable fans or other devices that generate air currents should not be used in the area during preparation procedures. Food or drink(s) are not allowed in hazardous drug or IV preparation areas at any time. Additionally, gum chewing, smoking or application of cosmetics is not permitted even if preparation activities are not in progress. Total external exhaust of BSCs in which hazardous drugs are compounded should be implemented when and where it is physically/structurally possible. The biological safety cabinet should never have its blower turned off except for maintenance or repair. The biological safety cabinet blower must be on and operating properly prior to use. Nothing should be stored on top of or near the biological safety cabinet that may damage the exhaust system or compromise the air quality in the cabinet. BSC s may not be located in area(s) with drafts or close proximity to other airflow devices, air vents, etc. BSC s must be certified upon initial installation, relocation, repair, and every 6 months thereafter. Environmental, Health, and Safety must be notified to facilitate relocation of any BSC or replacement of any HEPA filter(s). BSC must be sealed in plastic when moved or left inoperative for any extended period of time. 5:10.02 Personal Protective Equipment Requirements (PPE) Hand washing: Wash hands using appropriate hand washing technique with the antibacterial soap provided before gloving and after glove removal. Gloves: o Hand cleansing with an alcohol based product is required immediately prior to donning gloves. o Disposable, powder free (e.g. nitrile) gloves must be worn for all procedures involving hazardous drugs. Double gloving is required. One glove should be under the gown cuff and one over. o Routinely disinfect gloves with 70% Isopropyl Alcohol throughout all preparation

5 procedures. Gloves must be disposed of after each preparation period, when contaminated, or at least every hour. o Gloves must not be worn outside the hazardous drugs preparation work area. Gowns: o Long-sleeved, lint-free, solid front disposable, low permeability protective gowns with closefitting cuffs must be worn for all procedures involving hazardous drugs. o Gown(s) are discarded at the end of the shift or after a spill. o Gowns must not be worn outside the work area once preparation and/or reconstitution procedures have started. Masks o Facial masks or facial shields must be worn at all times in IV room(s) preparing nonchemotherapy drugs. o Facial masks and not facial shields are to be worn in chemotherapy production rooms. Shoe Covers o Shoe covers must be worn at all times in the IV room(s). Eye Wash Stations o Eyewash fountains or stations are located in or near each of the pharmacy areas where potentially hazardous products are stored or handled. 5:10.03 Cleaning the Biological Safety Cabinet (BSC) Biological Safety Cabinets (Vertical Air Flow) must be cleaned and disinfected regularly. Routine Cleaning: Clean the BSC with the Division designated cleaning and disinfectant products before beginning work, at the end of production, and when any spill occurs. See Section XV.6:03.07 Cleaning and Disinfection of Equipment. Clean in the following sequence: Clean the hanging bar Clean the back panel (top to bottom using horizontal overlapping strokes) Clean the side panels (start in the back of the hood and work toward the front/wipe top to bottom using vertical overlapping strokes) Clean the work surface (use horizontal strokes, working from the back to the front of the work surface) Dispose of gauze and gloves used to clean the hood with other hazardous waste. Do not attempt to clean the protective grill over the HEPA filter. More Extensive (Deep Hood) Cleaning Deep hood cleaning involves dismantling the work surface of the hood, for the purpose of cleaning the work surface undersides and drain spillage trough (drain pan). Procedures for deep hood cleaning must be followed. Deep hood cleaning must be performed each week for all BSC in use in the pharmacy and following chemotherapy spills in the hood. The method for deep hood cleaning is specific to the type of equipment being cleaned. Only personnel instructed in this procedure may perform deep hood cleaning See Attachment XV 5:08.03 for complete procedures.

6 5:11 Preparation of Hazardous Drugs 5:11.01 Preparation of Hazardous Drugs in a Biological Safety Cabinet (BSC) All preparations of IV admixtures and reconstitution of hazardous drugs must be performed in a BSC with vertical laminar air flow. No other drugs should be prepared in the BSC designated for the preparation of hazardous drugs. Special aseptic techniques and precautions must be used in BSC because of the vertical (downward) airflow. All manipulations must strive to contain the drug(s) being prepared in a closed system during transfers. When possible, only syringes with luer-lock tips should be used in the transfer of hazardous drugs from one container to another. Syringes should be large enough so that they are not full when containing the total drug dose. A closed system transfer device (CSTD) to admix drugs, such as the Phaseal or other safety system, must be used for all compatible hazardous drugs, or other designated products. Care through caution and appropriate preparation technique must be taken to avoid the puncture of protective gloves and possible self-stick(s) with hazardous agents. Plastic-backed absorbent (spill) cloth/drape(s) may be placed on the work surface during preparation or reconstitution procedure(s) of hazardous drugs. The spill cloths are not sterile and the plastic backing should be wiped with 70% Isopropyl Alcohol prior to use. Precautions to avoid touch contamination in product preparation must be used. All items required to complete an admixture or reconstitution procedure should be placed in the BSC before beginning work so that all manipulations can be completed without leaving and reentering the work area. Inspect solution and drug containers for expiration date, particulate matter, moisture, cracks or other defects. Place drug and solution containers in the cabinet only after they have been removed from their outer carton or wrapper. Solution containers and other similar objects should not be hung directly above the area where the drugs are prepared as they will impede the downward flow of clean air. Remove dust from non-sterile items with alcohol wipes before placing them in the biological safety cabinet. Arrange supplies for performing the preparation activity. Include enough syringes, needles, alcohol swabs, and zip lock bags to complete the admixture. When possible, arrange items in the BSC in a checkerboard pattern to decrease the possibility of cross contamination. Only items necessary to the preparation process should be placed in the work zone. No items should be placed over the front exhaust grills. Blockage of the grills may cause contaminants to enter or escape the BSC work area. Perform all manipulations at least three inches above the BSC work surface, working as far to the rear of the BSC as is comfortable to avoid contamination with unfiltered air from outside the hood. Work may not be completed close to the front or sides of the BSC where the air quality is lowest (clearance required is 6 inches). Paper wrapping and wipe pads must be kept away from all vent areas of the BSC to avoid being pulled into the blower fans. Drug preparation must be performed with the BSC glass window in the down position. If needed, personnel position should be adjusted to the recommended window height. Wait 2 to 3 minutes after materials and apparatus have been placed in the BSC before starting any preparation activity to allow laminar airflow to stabilize. In drug transfer, the fingers and hands should be positioned in such a manner as not to interrupt the

7 HEPA-filtered clean air to the sterile areas of needles, syringes, and sterile surfaces of drug solution containers. Needle and administration set insertions should be made with the critical sites perpendicular to the air stream, (e.g. - horizontal to the work surface) so that clean vertical airflow is not blocked. Wipe all external surfaces of the final drug container with the designated wipe product. Wipe the injection ports of the intravenous bags or bottles last with a clean alcohol wipe, and allow the alcohol to dry before removing the final product from the hood. Final hazardous drugs products must be placed in separate sealable containers (zipper-closure plastic bags). A light protective bag will be used to protect photosensitive drugs. Labeling must include hazardous drug labeling (universal chemotherapy label; caution: chemotherapy, etc) and follow standard medication safety requirements. Activities in the BSC should be performed at a normal pace -- no unusually fast movement. Avoid swinging arms into or out of the BSC as this creates turbulence and disrupts airflow in the cabinet. 5:11.02 Withdrawal and Transfer of Hazardous Drug Contents from an Ampule Before opening an ampule, ensure that no liquid remains in the neck and top of the ampule. Hold the ampule upright and tap the top to remove any liquid trapped in the ampule neck. Wipe the neck of the ampule completely with a sterile alcohol wipe. Allow 30 seconds contact time for disinfection Attach a 5-micron filter straw or a 5-micron filter needle to an appropriate size syringe. Leave protection cover on a straw or needle. Press plunger down towards tip of barrel to expel air and loosen plunger. Using a new alcohol wipe pad wrapped completely around the neck, grasp the ampule on each side with the thumb and index finger of each hand. Snap open the ampule, in a direction away from the preparer, by applying quick bending pressure, pulling up and away to prevent the fluid in the bottom of the ampule from splashing out. Remove protective covering from filter needle or straw. Tilt the ampule slightly and insert filter needle or straw into the fluid. Be careful to not to touch the ampule at the neck or exterior with the needle or straw. Withdraw required volume by pushing the plunger up with the thumb or index finger of the same hand in which the syringe is being held. Do not block the BSC vertical laminar airflow to the exposed sterile sites. To adjust measurement and remove air bubbles, remove the needle or straw from the ampule. To clear drug, pull back on plunger first before pushing forward, then slowly expel air. Excess fluid may be returned to the ampule. Remove the filter straw or needle. Aseptically attach an 18- or 20-gauge needle to the syringe. Inject drug in solution container whose port has been properly prepared. Place the ampule(s) in a zip lock bag. Swab all external surfaces of the final container and allow drying before removing from the BSC. 5:11.03 Withdrawal and Transfer of Hazardous Drug Fluid Contents from a Vial Using a Closed-System Transfer Device (CSTD) Hazardous drugs, with the exceptions of intra-arterial, intramuscular, and intrathecal doses, require the use of a CSTD during IV Preparation and/or administration. The CSTD (PhaSeal ) system required equipment and supplies include: CSTD (PhaSeal ) Assembly Fixture, Protector, Injector, and Infusion Adaptor

8 Luer-Lock Syringe Sterile Alcohol Gauze Pads IV Additive Bag The steps for preparation of hazardous drugs using the CSTD (PhaSeal ) system include the following: Remove the dust cover from the hazardous drug vial and swab the rubber stopper with a sterile alcohol wipe. Slide the vial into the assembly fixture clamp designed to hold the vial Place the appropriate size protector into the clamp of the assembly fixture designed to hold the protector Securely connect the protector to the vial by firmly depressing the assembly fixture handle Draw the required amount of air or diluent into the leur-lock syringe to be used in preparation of the dose Securely connect the injector s female luer base to the luer-lock syringe Remove the protective covering from the port of the IV bag used to connect the IV administration set Close both clamps on the infusion adaptor and securely connect the infusion adaptor to the port of the IV bag used for connection of the administration set Place the vial with the protector securely in place on a flat surface and connect the syringe/injector assembly o Insert the bayonet fitting of the injector into the protector s lock/connector o Turn the injector s syringe assembly a quarter turn to the right o Push the syringe/injector assembly down until the silicone cylinder covering the needle is retracted into the injector s housing. At this point the pathway between the syringe and the vial is open. With the vial on a flat surface inject the required volume of air into the vial After air has been added invert the vial/syringe assembly and withdraw the required drug volume into the syringe Separate (pull apart) the protector and injector housings until the injector s silicone cylinder has fully extended causing the injector s latch to snap back in place Turn the injector a quarter turn to the left and detach the syringe/injector assembly from the protector Connect the drug filled syringe/injector assembly to the infusion adaptor attached to the IV bag o Place the bayonet fitting of the injector into the lock/connector of the infusion adaptor o Turn the injector a quarter turn to the right o Push down on the syringe/injector assembly to retract the silicone cylinder into the injector s housing. The path between the syringe and IV infusion bag is now open. Inject the drug solution into the IV bag Pull back on the syringe/injector assembly until the silicone cylinder is fully extended. Rotate the injector a quarter turn to the left and remove the syringe/injector assembly Dispose of the syringe/injector assembly and vial/protector into a sharps container dedicated for hazardous waste.

9 5:11.04 Withdrawal and Transfer of Hazardous Drug Fluid Contents from a Vial - Without a CSTD Note: These procedures apply only in those cases in which CSTD components are incompatible with a given hazardous drug vial. Remove the protective cap on the vial. Swab the injection surface of the vial with 70% isopropyl alcohol. Avoid using excessive alcohol that leaves a pool on top of closure. Attach a Chemo Dispensing Pin to the vial top. Remove the Chemo Dispensing Pin port top and attach appropriate size syringe to port via luer lock. The syringe should be of sufficient size so that it will be no more than three-quarters full when final drug measurement is made. Be careful not to touch any part of the plunger except the flat knob at the end. Invert the vial and syringe. Pull back on the plunger to withdraw the proper amount of fluid. If air is in the syringe barrel, gradually inject the air in the vial, a little at a time. Do NOT inject all the air at once into the solution as foaming and/or excessive build up of pressure within the vial may occur. To remove air bubbles from the syringe, gently tap the barrel of the syringe to allow the air bubbles to surface. Push the plunger forward to expel air into the vial. Once the proper volume has been withdrawn, return the vial and syringe to the work surface. Pull back slightly on the plunger, "clearing" drug from the syringe tip. While holding the Chemo Dispensing Pin in place, remove syringe from the pin port, turning the syringe up after withdrawal to prevent leakage out of the syringe tip. Attach an appropriate sized needle to the syringe and inject contents of syringe into a solution container whose injection port has been properly prepared. Swab injection surface of admixtures before removal from cabinet. 5:12 Intrathecal Chemotherapy Preparation Intrathecal chemotherapy will be prepared in the pharmacy close to the time of administration and labeled with expiration time of eight hours or less Intrathecal chemotherapy syringes must be labeled FOR INTRATHECAL USE ONLY Intrathecal chemotherapy syringes must be placed in a sterile bag, wrapped in a 2 nd bag appropriately labeled with patient label and FOR INTRTHECAL USE ONLY At the time of dose preparation, Pharmacy will conduct a Time Out with two pharmacy personnel to independently verify and document drug, dose, and route. 5:13 Vinca Alkaloids Dispensing Requirement To prevent intrathecal administration of VinCRIStine and other Vinca alkaloids, doses of these agents will only be dispensed in an infusion bag. 5:14 Viral Products Viral Products will be prepared in a designated viral preparation area by authorized pharmacy personnel. See Attachment Section XV 5:14 Viral Products Standard Operating Procedures for additional requirements. 5:15 Disposal of Hazardous Drug Waste The EH&S department manages hazardous drug waste via the Hazardous Materials and Waste Management Plan. Disposal of all hazardous drug wastes shall comply with all applicable federal and state regulations Hazardous drug waste is contained, segregated, and disposed of separately from all other trash.

10 Proper disposal of all discarded hazardous drugs waste and items in designated hazardous waste or sharps containers is required. Removal of hazardous waste containers from pharmacy areas may be only by authorized building services staff. Although some drugs are not considered hazardous drugs by NIOSH, they are still regulated as hazardous waste by RCRA and will require disposal as such (P:\Quality Group\Hazardous Pharmaceuticals - List.xls) 5:16 Management of Accidental Contact with Hazardous Drugs Immediately rinse or flush area well (at least 3 minutes) with large amounts of water after exposure. Eyewash stations are located in each hazardous drug(s) preparation area. Wash with soap if applicable. Rinse well. Report the accident to the area supervisory staff. The area supervisory staff member will complete an accident report. If contact has been made with the eyes or other sensitive areas, seek medical attention AT ONCE either at employee health services (normal business hours) or the Emergency Center (24hrs/day). Refer to Material Safety Data Sheets (MSDS) for drug specific information (available online via link on Pharmacy computer desktop). 5:17 Management of Pharmacy Hazardous Drug (Chemotherapy) Spills Spill kit(s), clearly labeled, must be kept in each chemotherapy preparation area. Precaution(s) should be taken to prevent spills of hazardous drugs. 5:17.01 Actions Required with Hazardous Drug Spills All Pharmacy workforce members will follow institutional policy. See PPE and Management of Chemotherapy Spills Policy (UTMDACC Institutional Policy # ADM0171) If needed to contain or prevent spill spread o Wet spill - prevent spread with dry towels/gauze o Dry spill - prevent spread with damp towels/gauze. Report the spill to a Charge Pharmacist who will oversee the spill cleanup and documentation. 5:17.02 Hazardous Drug Spills in a Biological Safety Cabinet (BSC) Spills occurring in a BSC must be cleaned up immediately. For spill volumes from 0.1ml to 30ml, a spill kit or spill kit components that are available in each IV preparation area may be used to contain/clean up the spill. A spill kit must be used when the volume of the spill exceeds 30 ml or the entire contents of one drug vial or ampule is spilled For spills with a quantity of greater than 100ml, follow PPE and Management of Chemotherapy Spills Policy (UTMDACC Institutional Policy # ADM0171) Utility gloves (from spill kit) should be worn to remove broken glass in a BSC. Glass fragments should be placed in a puncture resistant hazardous drug waste container located in the BSC BSC (including the drain spillage trough) should be thoroughly cleaned and decontaminated. If the spill results in liquid being introduced onto the HEPA filter or if powdered aerosol contaminates the clean side of the HEPA filter, use of the BSC should be suspended until the equipment has been decontaminated and the HEPA filter replaced.

11 References: American Society of Health-System Pharmacists: ASHP Guidelines on Handling Hazardous Drugs. Am.J. Health-Syst.Pharm. 2006; 63: The United States Pharamacopeial Convention. <797> Pharamaceutical compounding sterile preparations (revision bulletin) Glossary: ASHP: American Society of Health-System Pharmacists EH&S: Environmental Health and Safety at M. D. Anderson Cancer Center NIOSH: National Institute of Occupational Safety and Health RCRA: Resource and Conservation and Recovery Act USP: United States Pharmacopeia