Attitude Shift: Making Safe Handling of Hazardous Drugs a Priority

MARTHA A. POLOVICH, PHD, RN, AOCN | March 22, 2017
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Martha A. Polovich, PhD, RN, AOCN

Martha A. Polovich, PhD, RN, AOCN

Concern about safe handling of hazardous drugs (HDs) now goes back more than a generation to the 1970s. Several chemotherapy agents were linked to secondary malignancies in treated patients, and astute clinicians suspected that healthcare workers (HCWs) might also be at risk. Data demonstrating the harmful effects of occupational chemotherapy exposure soon followed, all of which pointed to the need for protecting pharmacists and nurses.

Despite agreement among key stakeholders who support HCW safety when handling HDs, (Occupational Safety and Health Administration [OSHA]1National Institute for Occupational Safety and Health [NIOSH],2 American Society of Health System Pharmacists,3 and Oncology Nursing Society,4 there remains considerable variation in the use of safety precautions. Two of the most common misconceptions about HD exposure and HD precaution are (1) the chance of being exposed is small, and (2) there is no evidence to support all the recommended precautions.


Most oncology nurses accept the fact that HDs are harmful, and that exposure should be avoided.5 Yet, what some clinicians fail to recognize is that they are potentially exposed when performing routine handling activities or that they might be personally vulnerable to the adverse effects of exposure. Recent studies6-10 indicate nurses’ HD exposure is frequent enough to warrant concern (Table 1).

Many studies have detected HD residue on surfaces in healthcare settings,11-14 making exposure highly probable15 if nurses touch them without wearing personal protective equipment (PPE). Such contamination can occur from small leaks or from the transfer of HD residue from the outside of drug containers or gloves. The occurrence of environmental contamination has not improved significantly in the last 10 years.16,17 Some now consider this “invisible” contamination one of the most common sources of HCW exposure.

Table 1. Hazardous Drug Exposure Reported by Nurses
Drug Safe Handling Program

Table 1. Hazardous Drug Exposure Reported by Nurses
Several studies using biological monitoring documented the occurrence of occupational exposure by measuring HD residue in urine8,13,18,19 and genotoxic changes in peripheral lymphocytes of HCWs.20-23 A recent meta-analysis confirmed the overall effect of genotoxic damage as a result of occupational HD exposure.24 Whereas the magnitude of occupational exposure is likely small, the frequent, low-level exposure has potential adverse effects.


The HD safe handling precautions recommended in the 1980s were based on the best evidence available at the time. More than 30 years later, ample data exist to support biological safety cabinets (BSCs), closed system transfer devices (CSTDs), PPE, and a comprehensive safe handling program.25

BSCs and other types of ventilated cabinets are engineering controls designed for the purpose of protecting workers by preventing HDs from escaping into the work environment during drug preparation. Two examples of studies demonstrate the protective nature of BSCs. HCWs who do not use BSCs are exposed when compared to those who used them as evidenced by DNA damage.26 When BSCs malfunction, they have been associated with exposure.27

Table 2. Components of a Comprehensive Hazardous
Drug Safe Handling Program

Components of a Comprehensive Hazardous Drug Safe Handling Program
CSTDs are supplemental engineering controls. CSTDs are not used as commonly as other HD precautions, yet they represent the only engineering control available for HD administration. There are multiple studies demonstrating reduced surface contamination, which is a source of HCW exposure,19,28,29 as well as a decrease in actual HCW exposure.19

PPE—both gowns and gloves—provide barrier protection for HCWs when handling HDs. There are studies that demonstrate decreased worker exposure when PPE is worn compared with no PPE.26 In addition, contamination found on the outside of gowns and/or gloves would have resulted in worker exposure had they not been wearing PPE.30,31

Evidence exists to support the effectiveness of comprehensive safe handling programs for HD exposure control measures.32-34 Such programs address all aspects of HD handling, since combining strategies is more likely to result in worker safety (Table 2).


NIOSH15 endorsed double-gloving, chemotherapy-tested gowns and external venting of BSCs in  2004 . These recommendations appeared in the OSHA guidelines in the 1990s,35 although many considered these “suggestions,” and therefore optional.CSTDs are the only novel tools for safe handling of HDs, and the oldest of these has more than 15 years of data to support their use.
Because few recommendations for HD safe handling are new, it is unlikely that the inconsistent use of precautions is due to lack of awareness. Barriers to safe handling precautions do exist (Box).

Although some barriers are out of the control of HCWs and rest in the hands of facility leaders, others are due to perceptions and misconceptions of individuals. Attitudes about the low risk of exposure and the remote health effects may contribute to failure to use precautions
Barriers to Safe Handling

• Lack of availability of chemotherapy-tested PPE
• Discomfort from wearing PPE
• Not being convinced of the need for PPE5,10
• Concern that patients will be scared or worried when staff wear PPE5
• Cost of safety equipment6,25

PPE = personal protective equipment
Believing that PPE use is a “personal choice” is not harmless. Novice nurses learn from experienced nurses they respect. By modeling unsafe behavior, nurses send a message that exposure is not serious.

Because behavior change is related as much to attitudes and beliefs as it is to knowledge and skills, HD safety education must identify and address the affective domain. There should be a balance between fear and respect for those who are concerned about exposure. Because HD exposure and its potential for harm is not a matter of faith (ie, “I don’t believe it”), but one of toxicology, nurses must accept their personal susceptibility and value the precautions that are available.
1. US Department of Labor. Occupational Safety and Health Administration. Controlling Occupational Exposure to Hazardous Drugs. Accessed March 21, 2017.
2. Centers for Disease Control and Prevention. The National Institute for Occupational Safety and Health. NIOSH List of Antineoplastic and Other Hazardous Drugs in Healthcare Settings, 2016. Accessed March 21, 2017.
3. American Society of Health-System Pharmacists. ASHP Guidelines on Handling Hazardous Drugs. Am J Health-Syst Pharm. 2006;63(12):1172-1193. Accessed March 21, 2017.
4. Polovich M, Olsen M, LeFebvre KB, eds. Chemotherapy and Biotherapy Guidelines and Recommendations for Practice. 4th ed. 2014; Oncology Nursing Society: Pittsburgh, PA.
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Talk about this article with nurses and others in the oncology community in the General Discussions Oncology Nursing News discussion group.
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