UAMS ADMINISTRATIVE GUIDE

NUMBER: 11.4.13
DATE: 01/15/97
REVISION: 10/11/2004, 9/1/2007

SECTION: CAMPUS OPERATIONS
AREA: GENERAL AND OCCUPATIONAL SAFETY
SUBJECT: HANDLING CHEMOTHERAPY DRUG SPILLS IN CLINICAL & RESEARCH
APPLICATIONS

 

PURPOSE

This policy is to notify departments within the University of Arkansas for Medical Sciences (UAMS) of the procedures to be followed in protecting students, employees, patients, visitors and the environment from the potential hazards in managing chemotherapy drug spills.

SCOPE

All UAMS employees, faculty, staff, patients, visitors and students.

 

PROCEDURE (GENERAL)

(1)     Research laboratories, nursing units that administer chemotherapy agents, or other areas where chemotherapy agents are used should keep one spill kit available at all times.  In addition, the In-patient Pharmacy and the Department of Occupational Health and Safety will maintain an inventory of several kits for re-supplying these areas.

 (2)    Any employee or individual who initiates or is primarily involved with a spilling incident should begin immediate cleanup of any amount of chemotherapy agent spilled.  If problems develop or questions arise during normal working hours, contact either the Pharmacy (686-6221) or the Department of Occupational Health and Safety (686-5536).  After hours, contact the Pharmacy (686-6221) and Physical Plant Control Center (686-6424).

(3)    Surgical masks do not provide adequate protection for a hazardous drug spill.  Use NIOSH-Certified respirators (N-95 or cartridge respirator with HEPA filters.  Individuals must be properly trained and fit tested before a NIOSH-Certified respirator is worn.

PROCEDURE (DIRECT CONTACT WITH CHEMOTHERAPY AGENTS)

(4)     The following action should be taken for overt contamination of gloves or gowns or direct skin or eye contact with chemotherapy agent:

a)  Immediately remove the involved gloves or gown.

b)  Immediately wash the affected skin area with soap and water.  A physician should examine the affected area as soon as possible.

c)  For eye exposure, immediately flood the affected eye with water or eyewash designated for that purpose. Medical attention should be obtained immediately.

PROCEDURE (SPILLS IN HOOD)

 (5)    Spills involving chemotherapy material that occur inside a hood should be handled as follows:

a)  Leave blower on.

b)  Put on double gloves, gown, and eye protection. 

c)  If liquid, clean up with absorbent gauze pads or an absorbent pillow provided in the spill kit.  The absorbent should be gently placed on the spill so that liquid is not splashed about the hood.

d)  If solid, cover and wipe with wet (with water) absorbent gauze.

e)  Place the pad(s) with the absorbed chemotherapy material in a yellow bag.

f)   All contaminated surfaces should be thoroughly cleaned with detergent solution and wiped with clean water.

g)  Any broken glass fragments should be placed in a sharps container.

h)  If it is necessary to raise the hood’s sash to clean up the spill, a NIOSH-certified respirator and splash goggles must be worn during the cleanup.

i)   If a chemotherapy agent is spilled into the intake perforations of the hood, remove the work surface according to the manufacturer’s directions and thoroughly clean the drain pan in the proper manner, discarding all cloths and other materials used in the cleaning process.

j)   If for some reason the HEPA filter of a hood is contaminated with chemotherapy agents, the unit must be turned off.  A sign “Do Not Use - Contaminated” should be placed on the unit.  Personnel wearing protective gloves, goggles, NIOSH-certified respirator , and gown must change the filter as soon as possible according to the manufacturer’s instructions.  Whoever is changing the filter must be informed that it is a chemotherapy contaminate.  The filter should be placed in a yellow bag.

PROCEDURE (SPILLS NOT IN HOOD)

(6)     Spills involving chemotherapy material on counter tops, floors, or other areas outside a hood should be handled as follows:

a)  Isolate the area of the spill so that it is not disturbed by other personnel.

b)  Put on double gloves, gown, and eye protection.

c)  A NIOSH-certified respirator must be used when there is any danger of airborne powder or an aerosol being generated.

d)  If liquid, clean up with disposable absorbent toweling or absorbent pillow provided in the spill kit.  The absorbent should be placed gently on the spill so that liquid is not splashed.

e)  If solid, cover and wipe with wet (with water) absorbent gauze.

f)   Place the pad(s) with the absorbent chemotherapy material in a yellow bag.

g)  All contaminated surfaces should be thoroughly cleaned with detergent solution and wiped with clean water.

h)  Any broken glass should be placed in a sharps container.

i)   Non-cleanable items, including other drugs or supplies that may have been contaminated, must be put in yellow bag.

j)   Glassware or other contaminated items should be placed in a plastic bag so that they do not spread the spill, transferred to the sink, and then carefully washed with an appropriate detergent.  Avoid splashing while washing.

k)  Upon completion of the cleanup, the Biohazard Team should be notified to remove the bagged waste and the Housekeeping Department notified to perform any final cleanup of the area.

PROCEDURE (DOCUMENTATION)

(7)     In the event of a spill, the employee primarily involved in the spill will document the incident by the following means:

a)  If patient involved complete the UAMS Patient/Visitor Variance form (Patient Safety Net) and the UAMS Chemotherapy Drug Spill Checklist (pg. 4).

b)  If employee involved complete the UAMS Chemotherapy Drug Spill Checklist (pg. 4) and the Employee/Student Incident Report (Incident forms may be filled out by ER or Student Employee Health).

 

(8)     Upon completion, all documentation regarding the spill should be distributed to the following:

a)  Clinical Patient Care Areas must send documentation to the Department Occupational Health and Safety, Nursing Administration, Hospital Administration and Student/Employee Health.

b)  Research Areas must send documentation to their laboratory department head, the Department of Occupational Health and Safety, and Student/Employee Health.

PROCEDURE (MEDICAL SURVEILLANCE)

(9)     Employees having direct contact with a chemotherapy agent as a result of a spill must contact Student/Employee Health (686-6565) at the Department of Family and Community Medicine or ER (686-7925)on evenings, weekends, and holidays.  Employees should take with them a copy of the UAMS Chemotherapy Drug Spill Checklist.

(10)    If determined necessary by Student/Employee Health, the examining physician will be responsible for the following:

a)  Hemogram and a panel of four liver function tests.

b)  Complete health questionnaire if no previous records on the employee are available.

c)  Above lab study redrawn in two weeks.

 

 SIGNATURE: ________________________________  DATE: _________________________

 

UNIVERSITY OF ARKANSAS FOR MEDICAL SCIENCES

CHEMOTHERAPY DRUG SPILL CHECKLIST

 

  Patient Room or Lab # ___________________________________________Date of Spill ___________

 

  Patient Name (if applicable) ______________________________________Time of Spill ___________

 

 Staff  exposure

  _____________________________________________________________________________________

  _____________________________________________________________________________________

  _____________________________________________________________________________________

 

  Patient  exposure (if applicable)

  _____________________________________________________________________________________

  _____________________________________________________________________________________

 

  Name of Chemotherapy Agent _____________________________________________________________________________________

  Amount of agent in amount of solution _____________________________________________________________________________________

  Estimated amount of solution lost _____________________________________________________________________________________

  Signature of employee preparing checklist _____________________________________________________________________________________

 

 

Chemotherapy agent spill kits are available through the Department of Occupational Health and Safety
or the in-patient pharmacy.

 

  ________ 1.  Remove involved clothing immediately.

  ________ 2.  Flush eye(s) involved.

  ________ 3.  Wash skin involved with copious amounts of soap and water.

  ________ 4.  Move patient to another bed if the bed is contaminated;   transfer patient to another room if
                      large area  of the carpet is involved.

  ________ 5.  Isolate the area of the spill.

  ________ 6.  If problems develop or questions arise, notify the Department of Occupational Health
                      and Safety
 (during normal work hours) or the in-house pharmacy (weekends and

                         holidays).

  ________ 7.  An incident report and chemotherapy drug spill checklist should be completed with copies
                      to Department Heads and the Department of Occupational Health and Safety.

 

 

 

These forms are available from the Department of Occupational Health and Safety.  Units that might
require their use are strongly encouraged to have a supply available at all times.