Mr. Larsen presents to the clinic for his first dose of R-CHOP (rituximab, cyclophosphamide, doxorubicin hydrochloride, vincristine sulfate, and prednisone) for a diagnosis of diffuse large B-cell lymphoma. Elizabeth, his oncology nurse, just started the cyclophosphamide when she is paged to the desk for a call from Mr. Larsen’s oncologist. She quickly removes her face shield and gloves as she hurriedly leaves the room to take the call. After completing the call, she returns to Mr. Larsen’s room to remove her gown.  

Nurses in oncology who compound hazardous drugs may be familiar with the U.S. Pharmacopeial Convention (USP) because of chapter <795> related to compounding nonsterile medications and chapter <797> addressing compounding sterile medications. But what is USP really, and why does it have an impact on oncology nursing practice?

When patients go home after receiving their regimen of powerful cytotoxic agents, oncology nurses routinely encourage them to double flush after using the bathroom to ensure that trace amounts of hazardous medication are eliminated from the environment to prevent other members of the household from being exposed. But what happens with chemotherapy chemicals found in human waste as they enter a patient’s septic system—and eventually the water supply?

Last week, the American Society of Clinical Oncology (ASCO) released its 2019 safe handling standards. Although oncology nurses contributed to the expert panel, ONS does not endorse the ASCO standards because they differ from ONS guidelines and recommendations and guidelines from national and governmental organizations in several key ways. As an oncology nurse administering hazardous drugs, here’s what you need to know to keep yourself, your colleagues, and your patients safe.

Hazardous drugs are medications known to cause adverse health effects because of exposure in the workplace, according to the National Institute for Occupational Safety and Health. Examples of such agents include chemotherapy drugs, antivirals, hormones, and bioengineered drugs.

Which of the following drug spills doesn’t require a full-facepiece, chemical cartridge-type respirator or PAPR during clean up?

A. 5-Fluorouracil 

B. Cyclophosphamide 

C. Adriamycin  

D. Nitrogen mustard 

How frustrating it can be not to have enough evidence to answer a question definitively. That happens often in clinical practice, even as we build evidence for it. Expert opinion can help when the body of research does not. This spring, we have continued work in two areas in which answers are not definitive.

For sub-Saharan African (SSA) countries, cancer incidence is on the rise. The increase in cancer rates can be attributed to several factors, including economic and social development and infectious disease rates. In that part of the world, many healthcare professionals don’t have access to up-to-date information regarding safe chemotherapy handling and administration. The American Cancer Society (ACS) and Clinton Health Access Initiative (CHAI) developed the ChemoSafe program to share critical information and resource acquisition focused on safe chemotherapy administration and cancer treatments with healthcare providers in SSA. ONS provided specific nursing content to support the ChemoSafe initiative, including educational materials and courses.

Although USP Chapter <800> implementation has been delayed, ONS experts are receiving questions about clarifications and specifics for wearing gowns when handling hazardous drugs (HDs). Questions include topics such as hanging gowns and reusing, length of time gowns can be worn, the need for gowns with oral chemotherapy agents, and materials requirements of gowns. 

The U.S. Pharmacopeia (USP) announced on September 29, 2017, it would delay the implementation of USP General Chapter <800> Hazardous Drugs—Handling in Healthcare Settings to coordinate its implementation with chapter <797> Pharmaceutical Compounding—Sterile Preparations.  According to USP, chapter <797> is still undergoing revisions and will be available for public comment in fall 2018. UPS <800> was set for implementation by July 1, 2018, but both chapters are now expected to become official on December 1, 2019.

Because of the risks and dangers associated with hazardous drugs, guidelines surrounding their use and handling have been issued since 1981. Since then, several organizations, including ONS (in tandem with the American Society of Clinical Oncology), the American Society of Health-System Pharmacists, the Occupational Safety and Health Administration, and the National Institute of Occupational Safety and Health, have released guidelines for various providers who handle the drugs.

In a supplement to the April 2017 issue of the Clinical Journal of Oncology Nursing, ONS released its first set of recommendations for nurse education and safe handling principles regarding immunotherapy administration. ONS recommendations are based on best-available evidence and the anecdotal experiences of professionals at cancer centers with varied experiences in immunotherapy administration.

Research suggests that healthcare workers who handle hazardous drugs may experience acute effects such as skin rashes or more chronic effects including adverse reproductive events and malignancy. This has led numerous government agencies to make recommendations regarding the safe handling of hazardous drugs. 

The Institute for Safe Medication Practices (ISMP) has added five new best practices and revised two existing ones for safe medication administration in its recent release of the 2016-2017 Targeted Medication Safety Best Practices for Hospitals.

The ONS clinical inbox frequently receives questions about whether nurses need to be “chemotherapy certified” to give specific chemotherapy and/or biotherapy agents.

One of the questions that ONS commonly receives in the clinical inbox is whether nurses who are pregnant, breastfeeding, or trying to conceive can safely administer or handle chemotherapy and other hazardous drugs.