Developing a plan for properly managing pharmaceutical waste results in numerous benefits, including ensuring regulatory compliance, simplifying workflow, potential cost savings, and increasing environmental stewardship. Conversely, disposing of pharmaceutical waste without a well-planned strategy may expose a hospital to citations from regulatory agencies as well as unnecessarily increasing environmental contamination with pharmaceutical waste. 

Broward Health Medical Center (BHMC) is the largest safety net hospital in the four-hospital Broward Health system in Florida. Prior to 2008, the health system’s process for managing pharmaceutical waste consisted of segregating chemotherapy. All other medications were wasted in a common container with the exception of narcotics, which were flushed into the sewer system. Because one of Broward Health’s overarching goals is to increase environmental stewardship, developing a robust pharmaceutical waste management process throughout the health system became an important objective. Thus pharmacy, in concert with other departments, began evaluating the best way to dispose of pharmaceutical waste more responsibly. From late 2008 through early 2009, the four-hospital health system implemented a pharmaceutical waste management program.

Gaining Administration Buy-in
Presenting administration with persuasive evidence that the adoption of a pharmaceutical waste program will benefit the health system will ensure administration’s support throughout the decision-making process. Our administration was equally committed to reduce the impact of pharmaceutical waste on the environment, and this resulted in their willingness to assume the costs required for regulatory compliance. Each facility and health system will have its own primary motivation for implementing a pharmaceutical waste management program, be it ensuring regulatory compliance, decreasing waste costs, promoting an environmentally responsible culture, or reducing its carbon footprint. While these are all important considerations, the Broward Health administration considered its environmental responsibility as a top priority, along with regulatory compliance. A key first step is to identify the motivating factors at your institution and then tailor your proposal accordingly.

Contracting Considerations
Choosing a waste management partner is one of the preliminary considerations to implement an effective program. After evaluating the options, pharmacy and other leaders decided to partner with our existing vendor who managed our other waste streams. This expansion of our existing contract prevented the possible operational problems that can result from selecting a separate vendor and integrating a new automated system. Vendor selection was based on program comprehensiveness; important features for us included implementation assistance, staff education, ongoing monitoring post-implementation, and the option of reusable containers rather than disposable ones. Reusable containers have been recognized as a sensible practice to increase environmental stewardship and reduce operational costs.

Initiating the Program
Depending on their classification, medication containers require different disposal practices. One of our program’s top priorities was to standardize the available pharmaceutical waste containers, thus simplifying the process for the end user and ensuring regulatory compliance. Evaluating each hospital’s formulary and assigning classifications to every medication was one of our initial considerations, followed by assigning locations and determining the number of various waste bins required for every area where pharmaceuticals are delivered and administered. Hazardous medications, including toxic drugs, reactives, flammables, and corrosives, require strict segregation. We convened a multidisciplinary team to evaluate the volume of medications used in each department to determine how to sort and to dispose of them appropriately. The regulations and guidelines governing the disposal of chemotherapy and narcotics also were evaluated.

Taking a Team Approach
Ensuring all departments handling pharmaceutical waste are on-board is key to a successful implementation. To meet this goal, a robust staff education program was established, including online education; round-the-clock, unit-based in-services conducted by the vendor; and flyers posted in each waste disposal area to remind health care personnel of proper disposal for each medication. Challenges that were identified during the implementation phase were addressed immediately, including  appropriateness of container size and frequency of waste container pickups; required adjustments were made on an as-needed basis with the goal of avoiding staff frustration with the process change.

It is critical to involve all stakeholders, as the pharmacy, clinical end-users, and environmental services departments all have different needs and will assume responsibility for various aspects of the pharmaceutical waste program. Therefore, separate policies and procedures (P&Ps)—as well as education—were created to guide the process in disparate areas. These P&Ps include information detailing how each type of medication waste should be disposed of, the responsibilities of each staff member, and what education must be provided to new hires in each area and to end users on a yearly basis.

Benchmarks Drive Compliance
We tasked our vendor with the primary responsibility of removing pharmaceutical waste containers to avoid any risk from staff contact with discarded medications. We opted for an additional service wherein the containers are sorted at each Broward Health facility to evaluate compliance with disposal procedures by department. The vendor notes any sorting errors and this information is communicated to our hospital. With this rapid feedback, we can quickly respond to problems and avoid having poor practice become an ingrained habit.

Developing metrics to track program success as well as staff adherence is another valuable approach to identify areas for improvement. Our metric is computed using the aggregate of three months of pharmaceutical waste errors divided by the number of waste containers sorted. A benchmark was established after collecting a full year of data. The goal is to remain below the benchmark error rate of <1.00/quarter and strive for improvement in disposal practices. This information is shared with the safety officer, pharmacy manager, and department managers. By regularly reviewing this data we can identify potential error trends by department and then develop specific, targeted re-education for employees in those areas. Error rates are reported to us weekly by our vendor, which allows for timely resolution. The safety officer reports quarterly to the environment-of-care committee and administration.

Monitoring Patient Volume
During the implementation period we sought feedback from end-users on how to improve processes. Minor modifications made during the first year of implementation resulted in error rate reductions and improved compliance. To streamline workflow, we found it prudent to re-evaluate the locations of various waste containers, as well as the frequency of pickups. Based on patient census, patient medication volume in both the inpatient and outpatient settings was higher than originally anticipated and required the vendor to increase the frequency of pharmaceutical waste container pickups to accommodate these fluctuations. These changes were particularly important given the higher exposure to risk associated with overfilled containers. Simply by increasing the frequency of pickups we were able to significantly reduce this exposure.

Moving Forward
In the three years since initiating our pharmaceutical waste management program, several important benefits have been realized throughout the Broward Health system. The knowledge that our pharmaceutical waste is disposed of appropriately and from reusable containers ensures that our health system meets its environmental stewardship commitment. In addition, building a structured pharmaceutical waste management program in partnership with our vendor has inspired confidence that waste disposal meets regulatory requirements. Moreover, auditing our results and adjusting our processes accordingly has delivered cost benefits to our organization. We set a goal to decrease our sorting compliance error rate by 2% to 3% every year, and have experienced continuous reduction in the error rate every quarter over the past three years. Our future goals include exploring additional processes to further streamline workflow to improve environmental stewardship efforts. 

Shirley C. Ochipa, MS, MT (ASCP) SM, safety officer at Broward Health Medical Center, is responsible for regulatory and accreditation compliance of seven environment-of-care programs, including the hazardous material and waste program. She received her bachelors and masters in medical laboratory sciences from the University of Massachusetts. Shirley has experience in managing hospital clinical laboratories and as a director and faculty member of MT and MLT degree programs in colleges and hospital-based programs.

Brent J. Anderson, RN, RPh, CSLT, is the regional pharmacy manager at Broward Health Medical Center. He received his pharmacy degree from Xavier University College of Pharmacy and his nursing degree from Charity/Delgado School of Nursing in New Orleans.