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Recommendations for the safe handling of hazardous drugs have been available for more than twenty years. Evidence for continued risk of occupational exposure is abundant; however, nurses' use of the recommended precautions is not universal. This may be related to a lack of information or to a lack of serious concern for the potential hazards. This article includes a discussion of current issues related to handling hazardous drugs in the workplace and a review of the history of safe handling guidelines, current recommendations, and barriers to implementing guidelines in health care settings. © 2004 Online Journal of Issues in Nursing Article published September 30, 2004 [ABSTRACT FROM AUTHOR]

Purpose: To update the ASCO-Oncology Nursing Society (ONS) standards for antineoplastic therapy administration safety in adult and pediatric oncology and highlight current standards for antineoplastic therapy for adult and pediatric populations with various routes of administration and location., Methods: ASCO and ONS convened a multidisciplinary Expert Panel with representation of multiple organizations to conduct literature reviews and add to the standards as needed. The evidence base was combined with the opinion of the ASCO-ONS Expert Panel to develop antineoplastic safety standards and guidance. Public comments were solicited and considered in preparation of the final manuscript., Results: The standards presented here include clarification and expansion of existing standards to include home administration and other changes in processes of ordering, preparing, and administering antineoplastic therapy; the advent of immune effector cellular therapy; the importance of social determinants of health; fertility preservation; and pregnancy avoidance. In addition, the standards have added a fourth verification., Standards: Standards are provided for which health care organizations and those involved in all aspects of patient care can safely deliver antineoplastic therapy, increase the quality of care, and reduce medical errors.Additional information is available at www.asco.org/standards and www.ons.org/onf.

The Multi-Professional Oncology Safety and Simulation Training (MOSST) program, supported by the National Cancer Institute was launched in Fall 2018. The original workshop was conducted in person. As the COVID pandemic hit the program was transitioned to an online/distance simulation program using best practices in healthcare simulation design and implementation. The full day workshop was moved to an online platform using Zoom and the in-person simulations were re-developed as video branching case simulations. Learner outcomes that were identical in each modality were evaluated using the evaluation metrics from the original workshop. The use of a distance simulation modality to deliver the MOSST workshop resulted in a high-quality educational experience for the learners and the educational outcomes were comparable to the in-person version. Distance simulation using virtual unfolding case studies and didactic content showed comparable subjective and objective outcomes from participating learners. This work adds to the developing body of research on distance simulation.

Purpose: Drug therapy for cancer is a high-risk, high-volume clinical intervention that requires interprofessional teams. Given the complexity of anticancer drug therapy and safety concerns, an interdisciplinary team developed a novel training program for oncology registered nurses and pharmacists to improve cancer drug safety., Methods: Participants completed preworkshop learning assessments and received access to web-based modules on six topics: hazardous drug handling, drug extravasation, hypersensitivity reaction management, sepsis recognition, immune checkpoint inhibitor toxicities, and oral oncolytic adherence. In a 7-hour workshop, participants applied module content in interactive exercises and high-fidelity simulations. Preworkshop and postworkshop questionnaires assessed changes in knowledge and confidence in each topic. Program satisfaction and changes to clinical practice or policies were assessed 3 months after the workshop., Results: Two hundred ninety-two nurses and 82 pharmacists applied to participate, and 103 (35%) and 44 (54%) have participated, respectively. Long-term follow-up data were available on 133 (90%) participants. Change scores in confidence to meet program objectives increased between pre- and postworkshop (range of increase 0.6-0.8, P < .01). Knowledge scores increased significantly between pre- and postworkshop (average improvement of 3.2 points, P < .01). Overall program satisfaction was high (mean 5.0, standard deviation [0.2] on a five-point scale). Seventy-seven (60%) reported that they had made at least one clinical practice or institutional policy change at 3 months., Conclusion: An interprofessional education program with online modules, in-person interactive sessions, and simulation activities is a promising strategy to deliver cancer drug safety content to practicing oncology clinicians., Competing Interests: Karen B. FarrisConsulting or Advisory Role: QuiO, Birth Control PharmacistsResearch Funding: AstraZeneca MiKaela OlsenHonoraria: Becton DickinsonConsulting or Advisory Role: Beckinson and DickersonTravel, Accommodations, Expenses: Becton Dickinson Christopher R. FrieseConsulting or Advisory Role: RTI Health Solutions, LillyResearch Funding: Merck, National Comprehensive Cancer Network/PfizerOther Relationship: Patient-Centered Outcomes Research Institute (PCORI)No other potential conflicts of interest were reported.

Background: Antineoplastic drugs (AD) are important chemical risks for healthcare workers. Precautions against AD exposure include the use of appropriate personal protective equipment (PPE). Evaluation of PPE usage during patient care processes has not been reported in Thailand. We aimed to evaluate the level of PPE usage and factors predicting PPE usage among nurses and nurse assistants in Thailand., Methods: A cross-sectional survey was conducted in a university hospital and two general hospitals. The questionnaires covered demographic characteristics, self-reported use of PPE and 7 predictive factors. Mixed-effects modeling was used to determine the association between standardized score of predictive factors and PPE usage score., Results: The response rate was 78.6% and 884 participants were left for analysis after data cleaning. Among nurses (n = 499), higher PPE usage score was associated with self-efficacy (β = 0.28, 95% CI 0.21, 0.34), workplace safety climate (β = 0.27, 95% CI 0.20, 0.34), and conflict of interest (β = - 0.07, 95% CI - 0.14, - 0.01). Among nurse assistants (n = 385), higher PPE usage score was associated with self-efficacy (β = 0.27, 95% CI 0.18, 0.36), interpersonal influence (β = 0.14, 95% CI 0.04, 0.24), workplace safety climate (β = 10.29, 95% CI 0.19, 0.38), and conflict of interest (β = - 0.14, 95% CI - 0.24, - 0.03)., Conclusions: Several factors were associated with PPE usage among nurses and nurse assistants. Improved PPE usage against AD can be promoted through interventions that modify those factors.

Background: Hazardous drug exposure is an occupational health hazard to oncology nurses. Sparse data are available regarding the frequency and characteristics of hazardous drug spills., Objectives: This article aims to describe nurses' hazardous drug exposures and use of personal protective equipment during drug spills., Methods: The Drug Exposure Feedback and Education for Nurses' Safety study launched in March 2015. When drug spills occurred, consented RNs administering chemotherapy in ambulatory infusion settings completed brief questionnaires. Descriptive statistics were used to summarize equipment use and spill events., Findings: Spills were common, despite the use of closed-system transfer devices. Over two years, 51 nurses from 12 participating academic infusion centers reported 61 unique spills. Spills commonly involved highly toxic drugs. Personal protective equipment use during drug spills was suboptimal. These foundational data reveal gaps in clinical practice.

Objectives: To describe the nurse leader's role in implementing the hazardous drug safe-handling standards from USP General Chapter <800> that are most relevant to oncology nursing practice, and to provide strategies for reducing nurses' exposure to hazardous drugs., Data Sources: Published literature indexed in PubMed, CINAHL, textbooks, and clinical expertise., Conclusion: Nurse leaders are essential to promoting a safe environment for nurses handling hazardous cancer drugs., Implications for Nursing Practice: Several barriers and challenges to handling hazardous drugs exist and must be overcome before oncology nurses' exposure can be reduced., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objectives: To measure surface contamination with antineoplastic drugs on inpatient oncology units and to characterize nursing staff personal protective equipment (PPE) use and factors that predict this use., Sample & Setting: A descriptive pilot study of two inpatient oncology units at Duke University Hospital in Durham, North Carolina, administering etoposide and cyclophosphamide., Methods & Variables: Surfaces in four patient rooms and select shared areas were swabbed with methanol, acetonitrile, and water. Samples were analyzed by liquid chromatography tandem mass spectrometry. Nursing staff (N = 27) answered questions about their demographics, PPE use, and factors that influence PPE use via online survey., Results: Contamination with cyclophosphamide and etoposide was detectable and quantifiable in 61% and 31% of surfaces tested, respectively. Nursing staff reported suboptimal use of PPE when administering, disposing, and handling excreta of patients. Workplace safety climate was predictive of PPE use., Implications for Nursing: The potential for contamination with antineoplastic drugs in inpatient oncology units presents exposure risks for healthcare workers, patients, family members, and visitors. Future research and interventions to limit exposure and increase routine surface sampling should focus on those areas of greatest contamination, including toilet seats, a prominent finding from the current study.

Background: Chemotherapy agents have long been considered hazardous, and safety for healthcare providers when administering these drugs is a primary concern. Personal protective equipment (PPE) is known to decrease exposure to hazardous drugs. Studies report that PPE is underused among healthcare providers in inpatient and outpatient settings., Objectives: The purpose of this study was to examine the use of PPE among inpatient and outpatient nurses while administering hazardous chemotherapy agents., Methods: This cross-sectional, descriptive study used the Hazardous Drug Handling Questionnaire (HDHQ) to measure nurses' self-reported use of PPE., Findings: Results of the HDHQ indicated that nurses are not using PPE as recommended by hazardous drug administration guidelines. Interventions for proper PPE usage include interprofessional collaboration among oncology nurses, administrators, organizations, and healthcare systems to ensure the safety of healthcare providers, patients, and family caregivers.

Competing Interests: DisclosuresDr. Polovich has received speaker fees and travel expenses in the past year from BD, a manufacturer of closed-system drug-transfer devices (CSTDs). She is a consultant to the United States Pharmacopeial Convention (USP), but the comments in this article are her own and not those of USP. Ms. Power is an independent pharmacy consultant and member of the AJHP Editorial Board; in the past year, she has worked with Corvida Medical (Coralville, IA), a manufacturer of CSTDs. Ms. Power has presented programs sponsored by BD and ICU Medical, manufacturers of CSTDs, and attended Key Opinion Leader meetings sponsored by CSTD manufacturers CareFusion, Equashield, and Teva. Ms. Power is also an acknowledged coauthor of the National Institute of Occupational Safety and Health performance test protocol for CSTDs. Ms. Kienle is employed by Cardinal Health and is a member of the USP Compounding Expert Committee, but the comments in this article are her own and not those of USP or of her employer. The authors have declared no other potential conflicts of interest.

The U.S. Pharmacopeial Convention's "Chapter <800> Hazardous Drugs-Handling in Healthcare Settings" is a new part of the National Formulary that describes standards-expectations for practice-for all aspects of handling and administering hazardous drugs (HDs). Some of the standards will require changes in policies, procedures, and practices for nurses. This article provides an overview of the new standards and the impact they will have on nurses who prepare and administer chemotherapy and other HDs.
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Purpose: To update the American Society of Clinical Oncology (ASCO)/Oncology Nursing Society (ONS) Chemotherapy Administration Safety Standards and to highlight standards for pediatric oncology., Methods: The ASCO/ONS Chemotherapy Administration Safety Standards were first published in 2009 and updated in 2011 to include inpatient settings. A subsequent 2013 revision expanded the standards to include the safe administration and management of oral chemotherapy. A joint ASCO/ONS workshop with stakeholder participation, including that of the Association of Pediatric Hematology Oncology Nurses and American Society of Pediatric Hematology/Oncology, was held on May 12, 2015, to review the 2013 standards. An extensive literature search was subsequently conducted, and public comments on the revised draft standards were solicited., Results: The updated 2016 standards presented here include clarification and expansion of existing standards to include pediatric oncology and to introduce new standards: most notably, two-person verification of chemotherapy preparation processes, administration of vinca alkaloids via minibags in facilities in which intrathecal medications are administered, and labeling of medications dispensed from the health care setting to be taken by the patient at home. The standards were reordered and renumbered to align with the sequential processes of chemotherapy prescription, preparation, and administration. Several standards were separated into their respective components for clarity and to facilitate measurement of adherence to a standard., Conclusion: As oncology practice has changed, so have chemotherapy administration safety standards. Advances in technology, cancer treatment, and education and training have prompted the need for periodic review and revision of the standards. Additional information is available at http://www.asco.org/chemo-standards.

Approximately 8 million health care workers are unnecessarily exposed to highly toxic drugs used to treat cancer; antineoplastic drugs can contribute to negative health effects for these workers. The drugs have been detected in the urine of workers and on the floors and counters of worksites. Safety precautions that could reduce the risk of exposure are underutilized. This cross-sectional study of 163 oncology health care workers used a survey to measure workplace and individual factors, and environmental sampling to measure surface contamination. The study objective was to identify potential exposures to antineoplastic drugs and factors influencing safety behavior. Personal protective equipment (PPE) use was lower than recommended; unit of employment was significantly associated with PPE use. Chemical residue from antineoplastic drugs was found, revealing potential exposures. Workplace safety must be a higher organizational priority. The contamination of common work areas where PPE use is not expected was of utmost concern.

Purpose/objectives: To develop and test a worksite intervention that protects healthcare workers who handle antineoplastic drugs from work-related exposures. 
., Design: Intervention study. 
., Setting: A university hospital in a large midwestern metropolitan area and its outpatient chemotherapy infusion clinic.
., Sample: 163 staff (nurses, pharmacists, and pharmacy technicians) who work with antineoplastic agents.
., Methods: A self-report survey measured workplace and individual factors to assess use of personal protective equipment (PPE). Wipe samples were tested for surface contamination. An intervention incorporating study findings and worker input was developed.
., Main Research Variables: PPE use was the dependent variable, and the independent variables included knowledge of the hazard, perceived risk, perceived barriers, interpersonal influence, self-efficacy, conflict of interest, and workplace safety climate. 
., Findings: PPE use was lower than recommended and improved slightly postintervention. Self-efficacy and perceived risk increased on the post-test survey. Chemical residue was found in several areas. Awareness of safe-handling precautions improved postintervention. The unit where nurses worked was an important predictor of safety climate and PPE use on the pretest but less so following the intervention. 
., Conclusions: Involving staff in developing an intervention for safety ensures that changes made will be feasible. Units that implemented workflow changes had decreased contamination. 
., Implications for Nursing: Worksite analysis identifies specific targets for interventions to improve antineoplastic drug handling safety.

Purpose To update the ASCO/Oncology Nursing Society (ONS) Chemotherapy Administration Safety Standards and to highlight standards for pediatric oncology. Methods The ASCO/ONS Chemotherapy Administration Safety Standards were first published in 2009 and updated in 2011 to include inpatient settings. A subsequent 2013 revision expanded the standards to include the safe administration and management of oral chemotherapy. A joint ASCO/ONS workshop with stakeholder participation, including that of the Association of Pediatric Hematology Oncology Nurses and American Society of Pediatric Hematology/Oncology, was held on May 12, 2015, to review the 2013 standards. An extensive literature search was subsequently conducted, and public comments on the revised draft standards were solicited. Results The updated 2016 standards presented here include clarification and expansion of existing standards to include pediatric oncology and to introduce new standards: most notably, two-person verification of chemotherapy preparation processes, administration of vinca alkaloids via minibags in facilities in which intrathecal medications are administered, and labeling of medications dispensed from the health care setting to be taken by the patient at home. The standards were reordered and renumbered to align with the sequential processes of chemotherapy prescription, preparation, and administration. Several standards were separated into their respective components for clarity and to facilitate measurement of adherence to a standard. Conclusion As oncology practice has changed, so have chemotherapy administration safety standards. Advances in technology, cancer treatment, and education and training have prompted the need for periodic review and revision of the standards. Additional information is available at http://www.asco.org/chemo-standards .

The inherent toxicity of antineoplastic drugs used for the treatment of cancer makes them harmful to healthy cells as well as to cancer cells. Nurses who prepare and/or administer the agents potentially are exposed to the drugs and their negative effects. Knowledge about these drugs and the precautions aimed at reducing exposure are essential aspects of infusion nursing practice. This article briefly reviews the mechanisms of action of common antineoplastic drugs, the adverse outcomes associated with exposure, the potential for occupational exposure from preparation and administration, and recommended strategies for minimizing occupational exposure.

Background: Exposure to antineoplastic drugs confers health risks to workers, yet little is known about the exposure after a drug spill, nor has the relationship between exposure and organizational factors such as staffing and work environment been studied., Objective: The aim of this study was to evaluate drug spills prospectively using biological measures and correlate drug spills with organizational factors., Methods: Prospective questionnaires with 8-hour timed urine samples were collected from nursing and pharmacy personnel who reported drug spill events in 1 academic health center's infusion center. Urine was collected similarly from workers who did not report a spill. Liquid chromatography tandem mass spectrometry techniques identified detectable drug levels. After the prospective sampling period, workers were surveyed on workloads, practice environment, and safety behaviors., Results: From 81 eligible individuals, 40 participated in the prospective study and 19 completed retrospective questionnaires. Four spills were reported by 9 personnel, as multiple employees were exposed to drug spills. Four participants who reported a spill showed detectable levels of antineoplastic drugs. Four participants who did not report a spill had detectable levels of docetaxel. Compared with respondents who did not report a spill, collegial relations with physicians were significantly poorer for workers who reported spills., Conclusions: The study protocol successfully captured drug spill reports and biological samples. Workers have detectable levels of antineoplastic drugs through both drug spills and environmental contamination., Implications for Practice: Multisite research studies and practice-based quality improvement approaches are needed to improve adherence to personal protective equipment use and safe handling procedures.

Objectives: Antineoplastic drugs are known reproductive and developmental toxicants. Our objective was to review the existing literature of reproductive health risks to workers who handle antineoplastic drugs., Methods: A structured literature review of 18 peer-reviewed, English language publications of occupational exposure and reproductive outcomes was performed., Results: Although effect sizes varied with study size and population, occupational exposure to antineoplastic drugs seems to raise the risk of both congenital malformations and miscarriage. Studies of infertility and time to pregnancy also suggested an increased risk for subfertility., Conclusions: Antineoplastic drugs are highly toxic in patients receiving treatment, and adverse reproductive effects have been well documented in these patients. Health care workers with long-term, low-level occupational exposure to these drugs also seem to have an increased risk of adverse reproductive outcomes. Additional precautions to prevent exposure should be considered.

In 2009, the American Society of Clinical Oncology (ASCO) and the Oncology Nursing Society (ONS) published standards for the safe use of parenteral chemotherapy in the outpatient setting, including issues of practitioner orders, preparation, and administration of medication. In 2011, these were updated to include inpatient facilities. In December 2011, a multistakeholder workgroup met to address the issues associated with orally administered antineoplastics, under the leadership of ASCO and ONS. The workgroup participants developed recommended standards, which were presented for public comment. Public comments informed final edits, and the final standards were reviewed and approved by the ASCO and ONS Boards of Directors. Significant newly identified recommendations include those associated with drug prescription and the necessity of ascertaining that prescriptions are filled. In addition, the importance of patient and family education regarding administration schedules, exception procedures, disposal of unused oral medication, and aspects of continuity of care across settings were identified. This article presents the newly developed standards.

Purpose/objectives: To examine relationships among factors affecting nurses' use of hazardous drug (HD) safe-handling precautions, identify factors that promote or interfere with HD precaution use, and determine managers' perspectives on the use of HD safe-handling precautions., Design: Cross-sectional, mixed methods; mailed survey to nurses who handle chemotherapy and telephone interviews with managers., Setting: Mailed invitation to oncology centers across the United States., Sample: 165 nurses who reported handling chemotherapy and 20 managers of nurses handling chemotherapy., Methods: Instruments measured the use of HD precautions and individual and organizational factors believed to influence precaution use. Data analysis included descriptive statistics and hierarchical regression. Manager interview data were analyzed using content analysis., Main Research Variables: Chemotherapy exposure knowledge, self-efficacy, perceived barriers, perceived risk, interpersonal influences, and workplace safety climate., Findings: Nurses were well educated, experienced, and certified in oncology nursing. The majority worked in outpatient settings and administered chemotherapy to an average of 6.8 patients per day. Exposure knowledge, self-efficacy for using personal protective equipment, and perceived risk of harm from HD exposure were high; total precaution use was low. Nurse characteristics did not predict HD precaution use. Fewer barriers, better workplace safety climate, and fewer patients per day were independent predictors of higher HD precaution use. HD handling policies were present, but many did not reflect current recommendations. Few managers formally monitored nurses' HD precaution use., Conclusions: Circumstances in the workplace interfere with nurses' use of HD precautions., Implications for Nursing: Interventions should include fostering a positive workplace safety climate, reducing barriers, and providing appropriate nurse-patient ratios.

In November 2009, ASCO and the Oncology Nursing Society (ONS) jointly published a set of 31 voluntary chemotherapy safety standards for adult patients with cancer, as the end result of a highly structured, multistakeholder process. The standards were explicitly created to address patient safety in the administration of parenteral and oral chemotherapeutic agents in outpatient oncology settings. In January 2011, a workgroup consisting of ASCO and ONS members was convened to review feedback received since publication of the standards, to address interim changes in practice, and to modify the standards as needed. The most significant change to the standards is to extend their scope to the inpatient setting. This change reflects the conviction that the same standards for chemotherapy administration safety should apply in all settings. The proposed set of standards has been approved by the Board of Directors for both ASCO and ONS and has been posted for public comment. Comments were used as the basis for final editing of the revised standards. The workgroup recognizes that the safety of oral chemotherapy usage, nononcology medication reconciliation, and home chemotherapy administration are not adequately addressed in the original or revised standards. A separate process, cosponsored by ASCO and ONS, will address the development of safety standards for these areas.

Purpose/objectives: To determine patterns of personal protective equipment (PPE) used by oncology nurses while handling hazardous drugs (HDs) and to assess knowledge of the 2004 National Institute for Occupational Safety and Health (NIOSH) Alert and its effect on precaution use., Design: Descriptive, correlational., Setting: The Oncology Nursing Society 31st Annual Congress in Boston, MA, in 2006., Sample: 330 nurses who prepared and/or administered chemotherapy., Methods: Nurses described HD safe-handling precaution use by self-report survey., Main Research Variables: The availability and use of biologic safety cabinets and PPE., Findings: Respondents were well educated (57% had a bachelor's degree or more), experienced (X = 19, SD = 10.2 years in nursing and X = 12, SD = 7.9 years in oncology), and certified (70%; majority OCN®). Forty-seven percent of respondents were aware of the NIOSH Alert. Thirty-five percent of all participants and 93% of nurses in private practice settings reported preparing chemotherapy. Glove use (95%-100%) was higher than that reported in earlier studies, and gown use for drug preparation (65%), drug administration (50%), and handling excretions (23%) have remained unchanged. Double-gloving was rare (11%-18%). Nurses in private practices were less likely to have chemotherapy-designated PPE available, use PPE, and use spill kits for HD spills., Conclusions: Nurses have adopted glove use for HD handling; however, gown use remains comparatively low. Chemotherapy-designated PPE is not always provided by employers. Nurses lack awareness of current safety guidelines., Implications for Nursing: Nurses must know about the risks of HD exposure and ways to reduce exposure. Employers must provide appropriate PPE and encourage its use. Alternative methods of disseminating safety recommendations are needed.

Oncology units where patients with cancer receive chemotherapy are not the only settings where hazardous drugs are found. Because of increased use of antineoplastic agents for non-oncology indications, nurses' risk for occupational exposure is distributed more widely than in the past.

Standardization of care can reduce the risk of errors, increase efficiency, and provide a framework for best practice. In 2008, the American Society of Clinical Oncology (ASCO) and the Oncology Nursing Society (ONS) invited a broad range of stakeholders to create a set of standards for the administration of chemotherapy to adult patients in the outpatient setting. At the close of a full-day structured workshop, 64 draft standards were proposed. After a formal process of electronic voting and conference calls, 29 draft standards were eliminated, resulting in a final list of 35 draft measures. The proposed set of standards was posted for 6 weeks of open public comment. Three hundred twenty-two comments were reviewed by the Steering Group and used as the basis for final editing to a final set of standards. The final list includes 31 standards encompassing seven domains, which include the following: review of clinical information and selection of a treatment regimen; treatment planning and informed consent; ordering of treatment; drug preparation; assessment of treatment compliance; administration and monitoring; and assessment of response and toxicity monitoring. Adherence to ASCO and ONS standards for safe chemotherapy administration should be a goal of all providers of adult cancer care.

Carboplatin is used widely to treat cancers such as lung, breast, and ovarian. Hypersensitivity reactions (HSRs) to carboplatin can occur, often after numerous doses. The reactions can range from mild to life threatening. Oncology nurses witness the reactions and are instrumental in providing interventions to assist patients. Symptoms include flushing, rashes, itchy palms, nausea, difficulty breathing, back pain, hypotension, and tachycardia. Interventions include support of patients with oxygen and IV hydration along with administration of certain medications to diffuse HSRs. Predictive measures may include skin testing on patients who have received more than seven total doses of carboplatin, Desensitization protocols may be useful for patients with positive skin tests. Ultimately, with the potential for life-threatening reactions, patients and physicians need to consider the risk-to-benefit ratio of using the drug.