[MCOH-EH] Hazardous Drug Handling procedures

[Epps, Nancy]

With the new proposed 2014 USP 800 “Hazardous Drugs—Handling in Healthcare Settings” guidelines, our facility is looking into changing our practices but want to survey what other facilities are practicing:


1.      What cleaners/deactivators are you utilizing to clean your pharmacy areas (BSC-biological safety cabinet & CACI-compounding aseptic containment isolator) and administration areas? Alcohol, general disinfectant, or sodium hypochlorite & sodium thiosulfate combination? We currently clean our administration areas with a standard disinfectant and the pharmacy BSC and CACI with alcohol and a standard disinfectant.



2.      What quality control process do you utilize (administration areas and pharmacy areas)?  Is anyone doing wipe studies as the USP 800 recommends every 6 months? If so, please share the lab you utilize, frequency of studies, approx. costs, how you determine severity of results, and what you do with your results. We currently utilize initial education and annual observation, but no wipe studies as the USP 800 recommends.



3.      What medical surveillance do you practice?  What labs do you draw, how do you interpret (do you have a control group to compare them to), and do you do a health/reproductive questionnaire? Our facility stopped the health and reproductive questionnaire years ago due to staff complaints of ‘invasion of privacy’. We currently offer CBC, Chemistry & Liver panel (not UA). We do not sample a control group to analyze/interpret the lab data we receive to track trends.


Nancy Epps CMSRN, BSN, OCN
Clinician, Employee Health Services
Tampa General Hospital
Phone (813) 844-8003
Email: nepps at tgh.org

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