Safe Medication Handling: Concepts Beyond Cytotoxicity

The safe handling of a variety of pharmacologic agents is a vital component of the daily practice of pharmacy. Recommendations from the American Society of Health-System Pharmacists,¹ the National Institutes of Health,² and the Occupational Safety and Health Administration ³ were formalized nearly 20 years ago. Although these early documents focused primarily on the proper handling of cytotoxic medications, the safe handling of medications in today's practice should include considerations about the preparation, transportation, and administration of any medication, regardless of its cytotoxic potential.

Pharmacists and procurers of these products are a primary resource for nursing, medical, and hospital staff members who will share the responsibility for the safe handling of medications. Various institutions rely heavily on pharmacy support personnel in the preparation of sterile products, including cytotoxic medications. Individual states may govern the requirements that these individuals must meet in order to be responsible for such product preparation. Yet, all will rely on the ultimate supervision by a pharmacist to ensure accurate product preparation and employee safety. Nurses and prescribers generally will be responsible for administering the product to a specific patient, and hospital transportation staff members or volunteers may be asked to assist with the delivery of medications requiring safe handling to patient care areas. Every institution should have specific policies and procedures in place to assist employees with the safe preparation, transportation, and administration of medications.

The sterile preparation of medications in horizontal airflow hoods or vertical laminar-flow biological safety cabinets is widely used in both hospitals and noninstitutional settings today. It is well understood that the preparation of antineoplastic agents should take place in a Class II biological safety cabinet (BSC), whereas the sterile preparation of other noncytotoxic medications can safely occur in a horizontal airflow hood. Personnel are advised to wear appropriate protective clothing when preparing sterile products. Additional garments?such as closed-front gowns with cuffs?masks, and thicker surgical gloves are recommended when preparing agents with cytotoxic potential. Identifying medications other than the antineoplastics that may require preparation in a BSC is vitally important to maintain the integrity of the product and for the safety and health of those individuals responsible for product preparation.

Ganciclovir (Cytovene) is an antiviral agent used for the treatment of cytomegalovirus (CMV) retinitis in immunocompromised patients and for the prevention of CMV disease in transplant recipients. The manufacturer of ganciclovir recommends that handling and disposal of ganciclovir be done in accordance with the recommendations for antineoplastic agents. Ganciclovir has been shown to have carcinogenic and mutagenic properties in animal testing, and it impairs fertility when administered in humans.⁴

Cidofovir (Vistide) is another antiviral agent used for the treatment of CMV retinitis in patients with AIDS. The manufacturer of cidofovir recommends that it be prepared for intravenous (IV) administration in a Class II BSC and disposed of in the same manner as antineoplastic agents. Cidofovir also has demonstrated mutagenicity, carcinogenicity, and impairment of fertility in animal testing.⁵ Despite the lack of a formal guideline for the preparation of these 2 agents, it would be prudent to utilize a BSC when preparing IV cidofovir and ganciclovir solutions and to follow antineoplastic disposal recommendations.

The transportation of many therapeutic agents requires consideration regarding the safety and integrity of the individual product. Many institutions utilize pneumatic-tube delivery systems, which have weight and size limitations, depending on the manufacturer. Products transported in a pneumatic-tube delivery system are subject to significant motion, which may accelerate the destruction or denaturing of some medications, especially proteins and recombinant products. Also, narcotics, products that are difficult to obtain, or expensive items are not appropriate for transportation through pneumatic-tube delivery systems.⁶

The delivery of products by pharmacy personnel, volunteers, or nursing or transportation staff may vary by institution, but some general principles are extremely important to apply:

• Products should be clearly labeled as to what safe-handling procedures are required
• The staff should be educated on such procedures in an effort to avoid accidental exposures and to reduce waste
• Quality checks should be in place to identify areas for improvement and education

Other health care practitioners depend on pharmacists to provide the resources and safeguards that are necessary to maintain a safe working environment.

Last, but certainly not least, nursing and medical staff members are responsible for the final administration of IV medications to the patient. Appropriate labeling and education are vitally important to ensure that this final step is safely completed. Pharmacists rely on nurses to protect the patient from local irritation, consequences of extravasation, and other adverse events related to the administration of medications. This task is best accomplished when pharmacy and nursing staff members know best how to utilize their resources, ask questions, and collaborate to improve outcomes.

Many products extending beyond antineoplastics, immunosuppressives, and antivirals have specific administration concerns. Questions related to bolus administration times, IV compatibilities, and filtration requirements are commonly encountered by pharmacists. Newer technology has led to the development of novel administration devices that are sometimes challenging for a new user to operate. Dry-powder inhalers are supplied with step-by-step visual instructions for the patient, yet how many of us have delivered only the device to the nurse?

Providing in-service training on new medications and devices is a great way to strengthen the relationship between the pharmacy and nursing departments. This training helps establish pharmacists as the link between the nurse and the patient when medication safety is of concern. With a variety of references, the Internet, and pharmaceutical manufacturers' data at one's virtual fingertips, the ability to provide timely drug information services is greatly improved.

Safe handling of medications encompasses concepts that apply to their preparation, transportation, and administration. The importance of applying safe-handling principles to each of these measures cannot be expressed enough. Proper preparation of sterile products, regardless of cytotoxic potential, is the first step in ensuring a safe process. The transportation of medications using a variety of systems or personnel requires the implementation of appropriate safeguards. The administration of medications to patients is not a pharmacist's ultimate responsibility. A pharmacist's role is eminent, however, in providing support to nursing staff members so as to help protect patients and avoid unnecessary mistakes.

Dr. Huxtable is an assistant professor of pharmacy practice at Midwestern University College of Pharmacy?Glendale, and Mr. Garberding is a staff pharmacist at Banner Thunderbird Medical Center, Glendale, Ariz.

For a list of references, send a stamped, self-addressed envelope to: References Department, Attn. D. Ryan, Pharmacy Times, 241 Forsgate Drive, Jamesburg, NJ 08831; or send an e-mail request to: dryan@mwc.com.