The carcinogenic, mutagenic, and reproductive risks to patients receiving antineoplastic medications are well known, and the risks of chronic exposure to these medications in health care workers have been described for decades. A recent study evaluated health care workers who handled antineoplastic drugs and found that genetic damage—including significant increases in chromosomal aberrations, aberrant cells, and cells with micronuclei—was detected in these workers compared with their non-exposed peers.¹ However, knowledge of the health risks of exposure does not necessarily translate into adherence to safety practices.

–Regular education and thorough staff training are required to ensure nursing staff is protected from the dangers of hazardous drug exposure. –Staff training should begin upon hire, and regular retraining must occur thereafter. –Trainers should be clinical specialists with an extensive understanding of nursing workflow. Using spot checks is an effective method to maintain staff adherence after training. –These audits help identify practice challenges; nurses who are noncompliant with policies and procedures (P&Ps) should be reeducated. 

—The importance of developing and maintaining a culture of safety cannot be overemphasized. Review established guidelines from ASHP, OSHA, and NIOSH to ensure that hospital policies and procedures (P&Ps) are up-to-date and comprehensive. —While putting P&Ps in place is a good starting point, staff must also understand that they are expected to adhere to these policies at all times. If P&Ps are followed intermittently, nurses may begin to believe that safety is not valued at your hospital. The hospital culture must maintain a clear expectation that P&Ps are adhered to. 

—One approach we have found useful to highlight the possibility of hazardous drug exposure is using fluorescein to indicate the presence of chemotherapy in the nursing administration areas. —We employ fluorescein during staff training to demonstrate how to clean chemotherapy spills. —Using a blacklight, it is easy to view where the spill occurred and to illustrate how spills are often more widespread than they first appear. Although staff may believe the spill has been cleaned, oftentimes the blacklight identifies chemotherapy spattered on gowns, visible under the patient’s bed, etc. This exercise reinforces the need to use PPE and to follow P&Ps for cleaning spills carefully. 

Another education strategy is to use actual department incidents to identify strategies to prevent improper hazardous drug practices. Discuss the reasons why a spill occurred and the actions that could have prevented the spill, taking care to avoid blaming individual staff members. In addition, using real events as an education tool can help identify trends over time. If, for example, three spills occur in one year under similar circumstances, it may be an indication that increased training is required, a procedure needs to be modified, or equipment replaced.

References

1. El-Ebiary AA, Abuelfadl AA, Sarhan NI. Evaluation of genotoxicity induced by exposure to antineoplastic drugs in lymphocytes of oncology nurses and pharmacists. J Appl Toxicol. 2013;33(3):196-201.

Seth Eisenberg, RN, OCN, professional practice coordinator for infusion services at the Seattle Cancer Care Alliance Ambulatory Clinic, has been practicing in the field of oncology since 1983.

SIDEBAR
States Adopting NIOSH Guidelines as Law

NIOSH guidelines are voluntary, and NIOSH is not tasked with enforcing these guidelines. Nonetheless, in 2012, Washington State became the first in the nation to adopt the NIOSH hazardous drug handling recommendations as law. Recently, California and North Carolina passed similar legislation. To best ensure the safety of health care workers, pharmacists and nurses should get involved with their state legislators to adopt these recommendations. More information about Washington’s adoption of NIOSH guidelines is available at:http://www.lni.wa.gov/Safety/Topics/AtoZ/HazardousDrugs/