Safe Handling and Administration of Antineoplastic Chemotherapy

Barriers and facilitators for the safe handling of antineoplastic drugs

INTRODUCTION

Antineoplastic drugs are widely used in the treatment of cancer. However, some are known carcinogens and reproductive toxins, and incidental low-level exposure to workers is a health concern. CAREX Canada estimated that approximately 75,000 Canadians are exposed to antineoplastic drugs in workplace settings. While policies and guidelines on safe handling of antineoplastic drugs are available, evidence suggests that compliance is low. In this paper, we identify barriers and facilitators for safe handling of antineoplastic drugs in workplace settings.

METHODS

We utilized a unique method to study public policy which involved compiling policy levers, developing a logic model, conducting a literature review, and contextualizing data through a deliberative process with stakeholders to explore in-depth contextual factors and experiences for the safe handling of antineoplastic drugs.

RESULTS

The most common barriers identified in the literature were: poor training (46%), poor safety culture (41%), and inconsistent policies (36%). The most common facilitators were: adequate safety training (41%), leadership support (23%), and consistent policies (21%). Several of these factors are intertwined and while this means one barrier can cause other barriers, it also allows healthcare employers to mitigate these barriers by implementing small but meaningful changes in the workplace.

CONCLUSION

The combination of barriers and facilitators identified in our review highlight the importance of creating work environments where safety is a priority for the safe handling of antineoplastic drugs. The results of this study will assist policy makers and managers in identifying gaps and enhancing strategies that reduce occupational exposure to antineoplastic drugs.

Assessment of Nurse's Safe Behavior Towards Chemotherapy Management

Introduction

The management of chemotherapy in the hospital environment has been associated with increased risk of exposure to harmful factors. The use of the designated protective area and equipment during the preparation and the administration of chemotherapy is considered the gold standard of prevention.

Aim

The aim of the study was to assess nurse's behavior in one public and one private hospital during the management of chemotherapy.

Methods

A cross sectional study design, using a self-completing questionnaire was used to collect the data, the final sample consisted of n=82 nurses, employed in the oncology and haematology department of Limassol general hospital and the bank of Cyprus oncology center.

Results

Most of the sample had a positive attitude towards the management and preparation of chemotherapy and kept the personal protection measures 52,4%. Inadequate aeration system was found to exist in both the health care centers 17,1%. The knowledge levels of the nurses employed in the bank of Cyprus oncology center was found to be statistically higher than the nurses employed in Limassol general hospital (84,4% Vs 23,4%, p<0,001).

Conclusion

Educational programs need to be designed and implement to update nurses with the latest safety techniques and procedures, aiming at the protection of the employees from side effects as a result from the exposure to chemotherapy. The management of the healthcare institution need to ensure that the workplace environment fulfils all the safety standards and health regulations regarding the preparation of chemotherapy. Lastly more studies need to be conducted to monitor the knowledge and attitudes levels, and the implementation of safety and health regulation from the health care organizations regarding the safe management and preparation of chemotherapy.

Developing recommendations for the safe handling of oral anti-cancer drugs in community pharmacies: A pan-Canadian consensus approach

Purpose

To create a set of consensus-based and evidence-informed recommendations to provide guidance around the safe dispensing and handling of oral anti-cancer drugs in low-volume settings unique to the community pharmacy setting.

Methods

A review of published and grey literature (published in non-commercial domains such as national organizations and associations) documents and nine key informant interviews were conducted and a modified Delphi approach was taken to achieve consensus. The final list of 47 candidate recommendations was reviewed by a task force and validated by multi-disciplinary stakeholders. A draft of the statements was circulated broadly within the community pharmacy community in an effort to assess relevance and implementation feasibility.

Results

The final report included 44 recommendations that addressed 11 key areas germane to the safe handling of oral anti-cancer drugs in community pharmacies. Mean agreement increased from 70% to 95%. Early feedback from community pharmacy leaders during the external review suggests that many of the proposed recommendations can be feasibly implemented within a reasonable timeframe when released with appropriate education and resource materials.

Conclusions

A modified-Delphi approach supplemented by key informant interviews and a comprehensive external review resulted in a set of evidence-informed, community-driven recommendations for community pharmacies. The recommendations address a gap in existing literature to improve understanding of the risks associated with handling and dispensing oral anti-cancer drugs for both community pharmacy staff and management and offer mitigating strategies to reduce those risks. Incorporating feasibility assessment actions early (through the key informant interviews) and late (through the external review) ensures recommendations are grounded in practicality and support broad and early knowledge translation strategies.

Surface contamination of counting tools after mock dispensing of cyclophosphamide in a simulated outpatient pharmacy

PURPOSE

The primary aim was to determine if dispensing of cyclophosphamide tablets resulted in accumulated residue on pharmacy counting tools during a simulated outpatient dispensing process. Secondary objectives included determining if cyclophosphamide contamination exceeded a defined threshold level of 1 ng/cm² and if a larger number of prescriptions dispensed resulted in increased contamination.

METHODS

Mock prescriptions of 40 cyclophosphamide 50 mg tablets were counted on clean trays in three scenarios using a simulated outpatient pharmacy after assaying five cleaned trays as controls. The three scenarios consisted of five simulated dispensings of one, three, or six prescriptions dispensed per scenario. Wipe samples of trays and spatulas were collected and assayed for all trays, including the five clean trays used as controls. Contamination was defined as an assayed cyclophosphamide level at or above 0.001 ng/cm² and levels above 1 ng/cm² were considered sufficient to cause risk of human uptake. Mean contamination for each scenario was calculated and compared using one-way analysis of variance. P-values of < 0.05 implied significance.

RESULTS

Mean cyclophosphamide contamination on trays used to count one, three, and six cyclophosphamide prescriptions was 0.51 ± 0.10 (p=0.0003), 1.02 ± 0.10 (p < 0.0001), and 1.82 ± 0.10 ng/cm² (p < 0.0001), respectively. Control trays did not show detectable cyclophosphamide contamination. Increasing the number of prescriptions dispensed from 1 to 3, 1 to 6, and 3 to 6 counts increased contamination by 0.51 ± 0.15 (p = 0.0140), 1.31 + 0.15 (p < 0.0001), and 0.80 ± 0.15 ng/cm² (p = 0.0004), respectively.

CONCLUSION

Dispensing one or more prescriptions of 40 cyclophosphamide 50 mg tablets contaminates pharmacy counting tools, and an increased number of prescriptions dispensed correlates with increased level of contamination. Counting out three or more prescriptions leads to trays having contamination that surpasses the threshold at which worker exposure may be increased. Pharmacies should consider devoting a separate tray to cyclophosphamide tablets, as cross-contamination could occur with other drugs and the efficacy of decontamination methods is unclear. Employee exposure could be minimized with the use of personal protective equipment, environmental controls, and cleaning trays between uses. Future investigation should assess the extent of drug powder dispersion, the effects of various cleaning methods, and the potential extent of contamination with different oral cytotoxic drugs.

Oncology nurses' perspectives on safe handling precautions: a qualitative study

BACKGROUND

Oncology nurses can be exposed to hazardous drugs during their preparation, administration, transfer and storage and elimination of their waste.

AIM

This study was directed towards describing attitudes, opinions and experiences of nurses administering these drugs about safe handling precautions.

METHODS

A qualitative study design was used. Fifteen nurses working for at least three months involved in preparation, administration and transfer of antineoplastic drugs and management of wastes.

FINDINGS

Experiences, viewpoints and attitudes of nurses about safe handling precautions were analyzed in accordance with basic components of Health Belief Model.

CONCLUSIONS

Based on experiences, viewpoints and attitudes emphasized most by nurses, the most important factors about safe handling precautions were perceived barriers and cues to action. As well as heavy work schedules and high number of patients per nurse, lack of equipment and insufficient knowledge were found to be barriers to taking safe handling precautions.

Factors Influencing Nurses' Use of Hazardous Drug Safe-Handling Precautions

PURPOSE/OBJECTIVES

To identify factors associated with oncology nurses' use of hazardous drug (HD) safe-handling precautions in inpatient clinical research units.
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DESIGN

Descriptive, cross-sectional.
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SETTING

The National Institutes of Health Clinical Center in Bethesda, Maryland.
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SAMPLE

115 RNs working on high-volume HD administration units. 
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METHODS

Survey data were collected online using the Hazardous Drug Handling Questionnaire. Data were analyzed using descriptive statistics and multiple regression analysis.
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MAIN RESEARCH VARIABLES

Exposure knowledge, self-efficacy, barriers to personal protective equipment use, perceived risk, conflict of interest, interpersonal influences, workplace safety climate, and total mean HD precaution use.
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FINDINGS

Participants demonstrated high exposure knowledge, self-efficacy, perceived risk, interpersonal influences, and workplace safety climate. Participants demonstrated moderate barriers and conflict of interest. Total mean HD precaution use proved highest during HD administration and lowest for handling excreta at 48 hours. Average patients per day significantly influenced total HD precaution.

CONCLUSIONS

Despite high exposure knowledge, barriers to personal protective equipment use and conflict of interest may contribute to reduced adoption of personal protective practices among oncology nurses.
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IMPLICATIONS FOR NURSING

Hospital and unit-specific factors captured by the predictor variables could contribute to institutional HD policy.

Simultaneous quantification of vinblastine and desacetylvinblastine concentrations in canine plasma and urine samples using LC-APCI-MS/MS

A highly sensitive and specific liquid chromatography-atmospheric pressure chemical ionization-mass spectrometry (LC/APCI-MS/MS) method has been developed and validated for simultaneous quantification of vinblastine and its metabolite, desacetylvinblastine, in canine plasma and urine samples. Plasma and urine samples were processed by a solid phase extraction procedure. The optimal chromatographic behavior of these analytes was achieved on pentafluorophenyl (PFP) propyl analytical column (5μm, 50×2.1mm) under isocratic elution of 0.75mL/min with a mobile phase of 5mM ammonium acetate and methanol. The samples were analyzed in positive ion, multiple reaction monitoring mode. The calibration curves were linear over 0.125-2ng/mL (lower calibration curve); 2-100ng/mL (higher calibration curve) and 0.125-5ng/mL for vinblastine and desacetylvinblastine in plasma, and over 1-2000ng/mL and 0.5-100ng/mL for vinblastine and desacetylvinblastine in urine samples, respectively. The limits of quantitation of vinblastine and desacetylvinblastine were 0.125ng/mL in both matrices. The intra and interday accuracy was above 89% and precision below 8.6% for both analytes in both matrices. The developed method was successfully applied to ongoing in vivo vinblastine pharmacokinetic studies in dogs.

Intravenous administration of antineoplastic drugs: review of basics and what's new in 2009

Today, newer treatment regimens combine chemotherapy with targeted therapy, based on an improved understanding of cancer pathophysiology. New diagnostic testing with microarray technology is helping to identify mutational sequences in patient tumors, so individualized treatment of cancer will occur during our lifetime. The administration of IV antineoplastic drugs continues to be an important role of infusion nurses. In addition, this therapy has also found a niche in the treatment of nonmalignant conditions such as rheumatoid arthritis. This article reviews the fundamentals of administration of IV antineoplastic drugs and current issues and trends.

Current challenges in European oncology pharmacy practice

Background. The demand for pharmacy cancer services is expected to at least double over the next 10 years, as the population ages and new treatments are introduced. Safe and efficient handling of cytotoxic products minimises risks to staff and reduces medication errors.

Objectives. To identify and describe strategies for coping safely and effectively with heavier workloads in the hospital oncology pharmacy, currently and in the future.

Methods. The PubMed database was searched for literature on approaches to safe handling of antineoplastic agents and to decreasing medication errors in the hospital pharmacy. Articles that were judged to be of prime importance to the hospital oncologist were reviewed. These safety concepts are put into the context of contemporary hospital oncology pharmacy practice through discussion of key issues, including increased demand, the role of the pharmacist in determining the hospital formulary, and growth in patient preferences for oral chemotherapy. Recommendations on best practices are also provided, based on relevant literature and author experience.

Conclusions. Efficient, safe hospital pharmacy operations can be aided by capacity planning, dose banding, and knowledge of novel products and procedures that can reduce risks to health while increasing the number of patients who are safely treated. Consideration may also be given to the economic role of oncology pharmacists in formulary development. J Oncol Pharm Practice (2010) 16: 9—18.