Promoting a Culture of Safe Handling

April is National Safe Handling Awareness Month, a great time to spotlight the ongoing importance of implementing safe practices when handling chemotherapy and other hazardous drugs in the oncology setting—not only for healthcare practitioners, but for patients and their caregivers, too. Oncology Nursing News sat down to discuss this critical issue with an expert on the subject, Martha Polovich, PhD, RN, AOCN, at the Oncology Nursing Society (ONS) Connections meeting in Dallas, Texas.

Polovich, a clinical associate professor at Georgia State University in Atlanta, co-teaches an online chemotherapy course for ONS and is a reviewer on the update currently under way to the 2004 National Institute on Occupational Safety and Health (NIOSH) Alert.

Oncology Nursing News: How serious is the issue of chemotherapy administration safety today?

Polovich: It’s well known that antineoplastic agents, regardless of the route by which they are administered, are hazardous to the healthcare workers who handle them. That includes nurses and pharmacists. There is also concern for other employees who work in the area where these drugs are administered or prepared who are also at risk for exposure. These drugs are very good for the patients who need them to treat cancer and other serious diseases, but for healthcare workers, there’s no benefit to their exposure; the risk/benefit ratio is certainly not in their favor.

Recommendations about safety and preventing exposure date back to the late 1970’s— before many nurses who are now working in oncology were even born. The Occupational Safety and Health Administration (OSHA) issued guidelines in 1986, and ONS and phar - macy organizations also have safe handling guidelines.

Over the years, it was thought that exposure was no longer a problem when recommended interventions were put in place, but workers are still being exposed. More emphasis is needed on adherence to recommended guidelines to minimize exposure in the workplace.

What factors influence adherence to current safety guidelines in practice?

I don’t think we can blame lack of education, because anyone who is educated to prepare or administer chemotherapy does receive the information about the risks of exposure. I think the problem lies in the fact that practitioners remain unaware that they’re still being exposed in the workplace during routine handling.

Many studies—over 100 now—demonstrate that the environment where these hazardous drugs are handled is contaminated with them. Surfaces are contaminated, such as IV pumps and counters where the drugs are placed, and that doesn’t even account for the places where the drugs are being prepared. The external vials can be contaminated when they come from the manufacturer, and many people are unaware of that.

Some healthcare workers believe that if they put on a pair of gloves, they’re protected and thus are unaware that they’re being exposed, perhaps even taking chemotherapy home on their clothing and exposing their family members. One of the reasons they may consider themselves safe from exposure is that, thankfully, the adverse health outcomes don’t occur frequently enough to make the healthcare worker aware of them.

We don’t really know enough about the connection between individual health and exposure. I still hear stories of nurses who are handling chemotherapy and who have miscarriages and don’t connect it with their exposure; who have adverse health outcomes and don’t connect it with their exposure. That’s the problem, and there’s no clear link that they can make, so they’re not aware. If we don’t connect exposure with adverse outcomes, everyone thinks they’re okay.

What are one or two actions a practice might take that would make the most difference in improving safety?

I think there needs to be a culture of safety in the organization. Managers and supervisors need to get on board and make sure that nurses and other healthcare workers have access to the protective equipment they need and that they use it every time they handle hazardous drugs. If nurses don’t use precautions and they’re not called on it, then they think it’s okay. Nurses need to hold one another accountable, as well, for taking precautions.

According to all of the recommendations from organizations and government agencies such as NIOSH and OSHA, education and training is essential before you handle any hazardous drugs. That should be a requirement before handling, followed by validation of competency so that workers know what they’re supposed to do. This should be repeated on an annual basis.

Education and training is essential; it’s insufficient, however. You have to have the other support from management and from healthcare workers among themselves to make sure that everyone values and uses the precautions.

How can oncology nurses advocate for safe practice?

Someone in every organization needs to be the champion—whether it’s a pharmacist, a nurse, or a supervisor—someone who has the power to implement precautions and to make sure that policies support that. Policies are really important, because they represent a signal from the organization that they support safety.

The standards that are out there—and not just those related to safe handling—but also the ASCO/ONS Chemotherapy Safety Standards which address patient safety. Studies have demonstrated that if overall standards are followed in an organization, then safety standards for healthcare worker protection are also more likely to be used, and exposure is likely to be less.

What are your thoughts on closed system transfer devices (CSTDs)?

Many healthcare workers are unaware of CSTDs because they’re not being used in their organization. Cost is a concern because it adds to the cost of delivering chemotherapy, yet the cost of IV chemotherapy is so high, the addi - tional cost of CSTDs is really not that much.

Outside of drug preparation, CSTDs are the only engineering controls available for those who administer chemotherapy. If you prepare chemotherapy, you have a biological safety cabinet which provides protection from exposure. But on the administration side, there really isn’t anything if you don’t use a CSTD. Nurses use personal protective equipment to protect themselves when the drug leaks, which it often does. CSTDs prevent leakage or reduce it significantly, so there’s less exposure. If we really want to protect healthcare workers down the line, CSTDs are a good way to do that.