Case Study

Hazardous Drugs in Healthcare Settings:  Exposure to Antineoplastic Agents at Work

In 2017, a 41-year-old patient care assistant working on an oncology floor developed an itchy rash approximately 30 minutes after emptying a commode of urine into a toilet (Kusnetz & Condon, 2003). She denied any direct contact with the urine, wore a protective gown and nitrile gloves, and followed hospital policy for the disposal of materials contaminated with antineoplastic drugs. The rash subsided after 1 to 2 days. Three weeks later, she had a similar reaction approximately 1 hour after performing the same procedure for another patient. Upon investigation, it was found that both hospital patients had recently been treated with vincristine and doxorubicin. The patient care assistant had no other signs or symptoms and reported no changes in lifestyle and no history of allergies or recent infections. After treatment with diphenhydramine (intramuscular) and oral corticosteroids, her symptoms disappeared. Although the cause could not be confirmed, both vincristine and doxorubicin have been associated with allergic reactions when given to patients. The aerosolization of the drug present in the urine may have provided enough exposure for symptoms to develop in the patient care assistant (Department of Health and Human Services, National Institute for Occupational Safety and Health, 2004).

Recommendations

At a minimum, wear safety glasses with side shields and a face shield if splashing is possible when handling any possibly contaminated substance such as urine or feces. Wear two pairs of protective chemotherapy gloves and a disposable gown if handling linens, feces, or urine from patients who have received hazardous drugs within the last 48 hours. Before use, inspect gloves for defects and change gloves on a regular basis. The manufacturer’s documentation frequently provides glove-changing recommendations, and a facility risk assessment may provide other guidelines, but generally accepted practice is that gloves should not be used for more than 30 minutes. Remove the outer gloves and the gown by turning them inside out and placing them into the chemotherapy waste container. Repeat the procedure for the inner gloves. Always wash hands with soap and water before donning protective gloves and immediately after removal (American Society of Health-System Pharmacists, 2018; Polovich & Olsen, 2018).

Place wastes such as needles, empty vials and syringes, gloves, and gowns in chemotherapy waste containers. In addition to protective clothing, while disposing of contaminated materials in toilets, close the toilet lid or use a plastic backed absorbent pad placed over the toilet without a lid during flushing. Assuring that drug-contaminated waste is properly contained will protect workers from respiratory exposure to volatile or micro-aerosolized drugs. Fold soft materials (sheets, hygiene care products) inward to prevent leakage. Place in sealed bags.

Conduct regular training reviews with all potentially exposed workers in workplaces that use hazardous drugs. Make sure that training conforms to the requirements of the OSHA Hazard Communication Standard [29 CFR 1910.1200] and other relevant OSHA requirements such as the PPE standard [29 CFR 1910.132]. In addition, establish procedures for cleaning and decontaminating work areas and for proper waste handling and disposal of all contaminated materials, including patient waste.