Ensuring appropriate drug management throughout the entirety of the medication-use process is a core responsibility of hospital pharmacists. A comprehensive approach requires a compliant waste strategy for all pharmaceutical waste streams produced by the organization, including identification and disposal of nonhazardous waste, controlled substance waste, and RCRA hazardous waste.

Greenville Memorial Hospital is a 845-bed, tertiary referral hospital located in Greenville, South Carolina. A primary objective of our health system’s comprehensive waste management program is to decrease, if not eliminate, waste entering landfills and the water system. To accomplish this, every department and discipline that generates waste within the health system must participate in the process improvement effort. Pharmacy’s medication waste management strategy comprises a cradle-to-grave approach, which simplifies the process for staff while ensuring proper management. All formulary and inventory items are graded into their appropriate categories and assigned a color category that corresponds with their assigned waste container:

• Hazardous (including P- or >U-listed waste)=black
• Biohazardous and sharps=red
• Trace chemotherapy=yellow
• Nonhazardous medication waste=blue

Our waste vendor provides color-coded bins for each waste stream on the nursing units and within the pharmacies throughout the health system. Staff is trained to identify the correct waste stream for each type of waste and place items in the corresponding bins. The waste vendor collects bins when full and replaces them with empty receptacles.

Incorporating safe, compliant disposal of controlled substance waste can be particularly challenging when developing a comprehensive waste plan. In our health system, all controlled substances are disposed via a smart canister system that renders them inactive and unrecoverable. This method ensures that controlled substances do not end up in the sewer, which is one of the guiding principles of our overall waste management program.

Transitioning Waste Management Practices

Before we began sorting waste into their various waste streams in the pharmacies and on the nursing units, we utilized a system wherein all waste was disposed into a single container to be sorted by our waste vendor. While this was simple for staff, a decision was made to move to a system where staff is responsible for segregating medication waste into the appropriate containers. Our waste vendor provided the information required to code all of our formulary medications by waste stream.

Our hospital administration values compliance and green initiatives, and has been supportive of pharmacy’s waste management efforts. In fact, the directive to maintain regulatory compliance came directly from administration. Each department that utilizes medications (ie, pharmacy, nursing, respiratory, and radiology) is trained on waste classification. Our waste vendor provides the majority of this training, which occurs upon hire. Using the color codes in the eMAR, nursing is prompted as to the correct bin in which to waste a given medication. Pharmacy staff receives ongoing waste training as new items are added to formulary. With a commitment to training, we found the staff’s adjustment to the new waste management method to be easy.

Addressing Controlled Substance Waste

Novel approaches are increasingly available to avoid wasting controlled substances in the sewer and to help prevent diversion. Our health system chose to implement a battery-operated controlled substance smart canister containment system that renders this waste unrecoverable and unusable. The system secures partially administered or unused controlled substances, including solids, liquids, and patches.

A witness is required when wasting controlled substances into the canister system. Recognizing that this is not a foolproof method of preventing diversion, as it is possible for two staff members to work together to divert substances, we require that staff members use different witnesses each time they waste controlled substances. To ensure this occurs, and to create a visual record of controlled substance disposal, the area is monitored with digital cameras. In addition, we are able to trace waste documented in the ADCs, as the controlled substance waste canisters are located adjacent to the cabinets.

Once the canister is filled, the vendor removes the waste. The canister indicates when it is close to capacity and must be emptied, and also indicates when a new battery is required. The most significant concern when implementing the system was identifying where to mount it so it would not obstruct pharmacy workflow and so that all staff members, regardless of height and arm length, could access it. For example, if the system is mounted near a cabinet, make sure the cabinet door will still open after installing the canister. Because space is limited in the pharmacy, it is critical to carefully consider system placement to ensure it does not obstruct workflow and yet is accessible to all staff.

Benefits of A Comprehensive Waste Management Program

Regulatory Compliance

Ensuring compliance with state and federal regulations is a primary concern when developing a comprehensive waste disposal program. In addition, it is important to consider local regulations. For example, the local water board may contact a hospital to determine how it is disposing of a particular product that the board has identified in the water system. One of our health system’s top priorities is to meet all local, state, and federal regulations to ensure that all waste is disposed compliantly.

Peace of Mind

Pharmacy is extremely satisfied with our comprehensive waste management program. Robust staff training practices ensure that all waste streams are disposed properly, thus decreasing the amount of waste going into landfills and entering the water system. While the controlled substance containers require some maintenance (for example, replacing full containers and changing batteries), this is not overly burdensome. Staff quickly adapted to sorting waste, and pharmacy leadership and administration have peace of mind that we are doing all we can to ensure appropriate waste management and prevent diversion.

Future Goals

Looking ahead, our organization plans to reduce its waste footprint by decreasing the overall volume of medical waste produced. Strategies to realize this goal include improving purchasing techniques, evaluating expiration dates, and applying robust inventory management and medication utilization methodologies.

Jay E. Terry, PharmD, MBA, is the central pharmacy manager at Greenville Memorial Hospital. He earned his undergraduate degree at the University of South Carolina, an MBA at Francis Marion University, and his Doctorate of Pharmacy at the University of Florida.

SYSTEMS SCOOP
Greenville Memorial Hospital's waste vendors include:
   Waste Management Servces: Stericycle, Inc
   Controlled Substance Canisters: Styker (Cactus Smart Sink)