Still a work in progress?

Because of the risks associated with handling chemotherapy drugs, safety guidelines surrounding their proper use have existed since 1981.1 Both the Oncology Nursing Society (ONS) and the National Institute for Occupational Safety and Health (NIOSH) have recommended that oncology nurses receive training on hazardous drugs, including storage, preparation, l safe labelling, transportation, administration and disposal of hazardous drugs and the proper use of personal protective equipment (PPE).2

In 2016, the United States Pharmacopeial Convention (USP) updated the general chapter USP to set standards for the safe handling of hazardous drugs, with implementation of the new set standards scheduled for December 2019. Almost 3 years on USP has become the recommended standard, some hospitals have improved compliance, but Seth Eisenberg, ASN, RN, OCN, BMTCN, a retired oncology nurse now working as a consultant in Saint George, Utah, thinks implementation USP is still a work in progress for many hospitals.

USP requires pharmacies to store hazardous drugs in an externally ventilated negative pressure room with at least 12 air changes per hour,” Eisenberg said in an interview with Oncology Nursing News®. “For pharmacies that were housed in the basement of a hospital, this meant[ed] expensive changes. In some cases, it was more cost effective to build a new pharmacy than to upgrade an old one.

For nurses, USP compliance involves increased education on proper handling of hazardous drugs, implementation of closed-system drug transfer devices (CSTDs), and use of required PPE, according to Eisenberg. “One of the biggest changes in USP is the requirement to use CSTDs when administering drugs,” he said. “Although the ONS and NIOSH recommended these devices, they were not needed.”

CSTDs can prevent or minimize drug leaks, but Eisenberg said the cost can be prohibitive for some hospitals and clinics. “[Because] some components of CSTDs are for single use, this increases the overall cost of the drug,” he said. “The average price of a CSTD ranges from $8 to $12 per dose.”

In addition to CSTDs, USP requires nurses to wear double gloves and wear chemotherapy gowns when administering chemotherapy drugs, which is in line with ONS guidelines.

“NIOSH has been providing best practice guidance for over 2 decades. But USP is an enforceable standard with far-reaching implications for all facilities that handle hazardous drugs,” says Eisenberg.

Meet enforceable security requirements

Although guidelines for the safe handling of hazardous oncology drugs are not new, USP introduced security standards that could be applicable at the state level.

USP gave bite and applicability to safety practices that already existed,” explained AnnMarie Walton, PhD, MPH, RN, OCN, CHES, FAAN, assistant professor at the School of Nursing at Duke University in Durham, in North Carolina, in an interview. with Oncology Nursing News®. “Execution USP is still a work in progress for many oncology units. Some of the oncology units that were not previously using CSTDs are adopting them now that providers are able to meet demand. Opposability of the USP The requirement is decided and regulated at the state level. »

Walton said oncology nurses are well positioned to advocate for safety changes and encourage adoption of USP if their unit has not already implemented them. Additionally, oncology nurses can educate patients and their caregivers about safety measures to follow while administering chemotherapy in the hospital or at home after the patient is discharged.

Ensuring outpatient safety

MiKaela M. Olsen, DNP, MS, APRN-CNS, AOCNS, FAAN, director of the clinical oncology program at Johns Hopkins Hospital in Baltimore, Maryland, works at a hospital that began offering an injection clinic in curbside to oncology patients in 2020, during the peak of the pandemic.

“We needed to find a way to ensure that our patients could safely continue to receive chemotherapy while protecting them from the coronavirus,” Olsen said. Oncology Nursing News®.

Johns Hopkins originally designed curbside injection clinics as a precaution during the pandemic. But Olsen said Johns Hopkins plans to continue these clinics for patients receiving chemotherapy, and other hospitals have taken notice. “For many oncology patients, the curbside injection clinic offers both increased safety and convenience,” Olsen said. “They still have the option of our indoor injection clinic, but for patients with transportation and mobility issues, the curbside clinic is easier. They can have a family member drive them or take an Uber or Lyft to their appointment.

Nursing staff at the curbside injection clinic wear full PPE, follow safety protocols, and offer services such as symptom assessments, port rinses, dressing changes, and chemotherapy. To date, the curbside injection clinic has seen over 7,000 patients. Although large healthcare systems such as Johns Hopkins have adopted USP Olsen acknowledged that some small community hospitals are still struggling to implement USP security requirements. One way for hospitals to do this is to request a health risk assessment from NIOSH. This assessment identifies potential health risks and recommends ways to reduce exposure. There is no cost for the assessments, but they pay off with peace of mind. “Compliance challenges vary from one health care setting to another, but nurses can help identify areas that need improvement,” Olsen said.


  1. Bernabeu-Martínez MA, Ramos Merino M, Santos Gago JM, Álvarez Sabucedo LM, Wanden-Berghe C, Sanz-Valero J. Guidelines for the safe handling of hazardous drugs: a systematic review. PLoS One. 2018;13(5):e0197172. doi:10.1371/journal.pone.0197172
  2. Huff C. USP compliance : a project to improve the quality of safe handling of hazardous drugs for infusion nurses in ambulatory care. Doctoral thesis in nursing practice. University of San Francisco; 2020.

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