Introduction
A hazardous drug (HD) is a drug that can harm the people who handle it, not only the patient who receives it. Most HDs in veterinary practice are chemotherapy drugs, but some sedatives, antithyroid drugs and immune suppressants are on the list too.2 The technician receives these drugs, stores them, helps prepare and give them, cleans up after the patient and throws away the waste. Each of those steps can expose staff. This guide covers HD handling, spill response, storage and temperature logs, Safety Data Sheets (SDS) and labels, and the right waste stream for each item, including expired and controlled drugs.
Key facts
- NIOSH calls a drug hazardous if it shows carcinogenicity, teratogenicity or developmental toxicity, reproductive toxicity, organ toxicity at low doses, or genotoxicity, or mimics a known HD.2
- No level of HD exposure is considered safe.2
- PPE for HD work: chemotherapy-rated double gloves, a long-sleeved impermeable gown that closes in the back, and eye or face protection when splashing is possible.1
- Oral chemotherapy tablets are never crushed or split, and capsules are never opened.1
- Treat excreta as contaminated for at least 48 to 72 hours after injectable chemotherapy, and perhaps up to 7 days after oral chemotherapy.1
- Trace chemotherapy waste (less than 3% of the original quantity) goes in the yellow chemotherapy waste container in the United States.1
- Vaccine refrigerators should hold 2 to 8 degrees C (36 to 46 degrees F); check and record minimum and maximum temperatures at the start of each workday.6
- Hazardous waste pharmaceuticals must not be poured down a drain, and controlled drugs must be destroyed so they are non-retrievable.58
How the VTNE tests this
- Choose the correct PPE or engineering control for a chemotherapy task (Domain 1 Task G; K10, K11).9
- Put the steps of a spill cleanup in order, or pick the item a spill kit must contain.
- Match a product to its storage condition, or decide what to do after a refrigerator temperature excursion (K37).
- Sort an item into the right waste container: sharps, trace chemotherapy, hazardous pharmaceutical or controlled substance.
- Find information on an SDS or read a GHS pictogram.
Core concepts
Why HDs are a staff hazard
Many chemotherapy drugs are carcinogenic (cause cancer), mutagenic (damage DNA), teratogenic (cause birth defects) or abortifacient (cause pregnancy loss).1 Staff can be exposed through skin contact, splashes to the eyes or mouth, swallowing, breathing aerosols or particles, and needlestick injuries.2 Exposure can happen at every step: receiving, storing, dispensing, giving the drug, cleaning, and handling the animal's urine, feces and vomit.2
Workers who are pregnant, breastfeeding, or trying to conceive or father a child should avoid exposure or reduce it as far as reasonably practicable. The ACVIM statement says they should not prepare or give HDs, handle treated patients, or clean their cages, and should be offered other duties.1
Which drugs are on the list
The NIOSH list of hazardous drugs is the reference that USP General Chapter <800> uses to decide which drugs are hazardous. USP <800> is the standard for safe HD handling in healthcare settings, and it applies to veterinary workers too.2 NIOSH updates the list, so check the current edition before you build a clinic list.2
| Type | Examples a technician will meet |
|---|---|
| Antineoplastic (chemotherapy) | Carboplatin, chlorambucil, cyclophosphamide, doxorubicin, lomustine, vinblastine, vincristine |
| Other HDs | Chloramphenicol, cyclosporine, diethylstilbestrol, methimazole, phenoxybenzamine, spironolactone |
| Reproductive risk | Misoprostol, fluconazole, zonisamide, clonazepam |
Source: New Jersey Department of Health veterinary toolkit table, based on the NIOSH 2016 list.2
Hierarchy of protection
Engineering controls contain the drug at its source, and PPE protects the person. A biological safety cabinet (BSC) or a compounding aseptic containment isolator is the primary engineering control for preparing chemotherapy.1 A closed-system transfer device (CSTD) is a set of vial adaptor, syringe connector and line adaptors that mechanically stops drug or vapor from escaping. It also lowers the risk of needle accidents.1 Luer-lock syringes and needleless devices are other simple controls.2
Procedure or technique
Receiving and storing HDs
- Wear gloves when you handle incoming HD inventory. Surface contamination of vials is common when they arrive from the manufacturer.12
- Label packages, bins, shelves and storage areas as hazardous. Post a list of the clinic's HDs.2
- Store HDs in a separate, labeled area, away from other stock and away from food and drinks.12
- Follow the label for refrigeration, room temperature or light protection.1
- Keep a spill kit in receiving, preparation, administration and patient-holding areas.1
Preparing and giving chemotherapy: the technician's role
- Two separate people check the dose calculation independently before preparation.1
- Put on full PPE. Place a plastic-backed absorbent pad on the work surface. Work inside the BSC, at least 3 inches above the work surface.1
- Spike fluid bags and prime tubing with a compatible fluid before the HD is added.1
- Label the final product as cytotoxic and seal it in a transport bag.1
- Two trained people give the drug, working below eye level with a plastic-backed pad under the site.1
- Remove the IV catheter with lines and tubing intact, then peel the outer glove off inside out around it.1
- Do not wear a gown longer than 3 hours. Discard gloves after each use and wash your hands.1
Caring for the treated patient
Drug may appear in urine, feces, saliva, vomitus and sebum.1 House treated patients in dedicated cages in a low-traffic area. Use disposable materials where possible and label the cage with a cleanable sign naming the drug and its main route of excretion.1 Do not use sprayers or pressure washers for the first cleaning of the cage.1
Spill response
Contain and clean a spill at once. One trained person manages it, and cleaning always moves from the less contaminated area toward the more contaminated area.1 A spill kit holds:1
- PPE
- Enough absorbent material for a 1000 mL spill, plus plastic-backed absorbent sheets or pads
- Disposable towels
- At least 2 sealable, thick, pre-labeled hazardous waste bags
- A disposable scoop and a puncture-resistant container for glass
Absorb liquids with a pad. Wet the towels before you wipe up a dry spill so you do not raise dust. Document the drug, the approximate volume, how the spill happened, how it was managed and who was exposed.1
Storage and waste tables
| Product | Condition | Technician check |
|---|---|---|
| Refrigerated vaccines | 2 to 8 degrees C (36 to 46 degrees F) | Record min and max temperature at the start of each workday6 |
| Refrigerated vaccines, especially adjuvanted liquids | Never frozen: one exposure to 0 degrees C (32 degrees F) or colder can destroy potency | Vaccine appearance does not show damage; check the log6 |
| Light-sensitive products | As labeled (light-sensitive) | Follow the storage directions on the label1 |
| Hazardous drugs | As labeled, in a separate labeled area | Away from other stock and food12 |
| Controlled substances | Securely locked, substantially constructed cabinet | See the controlled substances guide10 |
Sources: CDC Vaccine Storage and Handling Toolkit; ACVIM consensus statement; NJDOH toolkit.
Potency lost to heat, cold or light cannot be restored.6 If the log shows an out-of-range reading, label the exposed vaccines "DO NOT USE", keep them apart in a separate container and report the excursion before anything is given or thrown away.6
| Item | Waste stream |
|---|---|
| Empty vials, gloves, gowns, pads with trace chemotherapy (less than 3%) | Yellow chemotherapy waste container: labeled, leak-proof, foot-pedal lid1 |
| Needles, glass and other sharps from HD work | Puncture-proof container1 |
| Bulk HD, spill cleanup bags | Hazardous chemical waste under EPA/RCRA, removed by a licensed waste company1 |
| Hazardous waste pharmaceuticals | Never sewered (sink or toilet)5 |
| Expired or unwanted controlled drugs | Destroyed on site so they are non-retrievable, or sent to a DEA-registered reverse distributor78 |
| Cat litter at home after chemotherapy | Double-bagged with household trash1 |
Sources: ACVIM consensus statement; 40 CFR 266.505; 21 CFR 1317.05 and 1317.90. State and local rules can add requirements.
Flowchart
Species differences
- Dogs: solid waste should be picked up with gloved hands and double-bagged in impermeable bags for household trash. Blot liquid waste dry, then clean with dilute bleach.1
- Cats: litter boxes should be cleaned daily, and litter double-bagged and discarded with household trash.1
- Horses and large animals: stalls of treated horses count as contaminated housing. Do not use sprayers or pressure washers for the first cleaning.1
- All species: if safe administration cannot be guaranteed, chemical restraint or the decision not to treat is up to the prescribing clinician.1
Safety, legal and client education
SDS and labels. OSHA's Hazard Communication Standard guidance says facilities that use HDs must train workers, label HDs adequately and give access to an SDS for every HD in the hospital.1 An SDS has 16 sections in a fixed order. Section 2 gives hazard identification, Section 4 first aid, Section 6 accidental release (spills) and Section 8 exposure controls and personal protection.4 Under the Globally Harmonized System (GHS), the Health Hazard pictogram marks carcinogens, mutagens and reproductive toxins. The skull and crossbones marks acute toxicity. Each pictogram appears only once on a label.3 See figure 3 for the full set.
Client education for home chemotherapy. Teach the owner to wear disposable gloves when giving tablets, to give them whole, and to wash hands afterward. Clean soiled areas with disposable towels, double-bag solid waste, and clean the area with dilute bleach after gross material is removed. Wash soiled bedding and towels twice, separately from other laundry.1
Exposure. After an eye splash, flush the eye; staff should be trained in this first aid.2 Section 4 of the SDS gives first aid measures.4 Workers with a large spill, a skin or eye contact or a needlestick should have medical follow-up.1
Common mistakes and exam traps
- Crushing or splitting an oral chemotherapy tablet to fit a small dose. Never do this; the clinician must choose another dose form.1
- Cleaning a spill from the center outward. Clean from the less contaminated edge toward the center.1
- Using a single pair of exam gloves. HD work needs chemotherapy-rated double gloves.1
- Pouring leftover drug down the sink. Hazardous waste pharmaceuticals may not be sewered.5
- Throwing a refrigerated vaccine away the moment the log is out of range. Isolate it, label it "DO NOT USE" and report it.6
- Thinking that a frozen-then-thawed vaccine that looks normal is fine. Appearance does not show lost potency.6
Quick review
- An HD harms the handler: carcinogenic, teratogenic, reproductive, genotoxic or organ-toxic at low doses.
- No HD exposure level is safe.
- Engineering controls (BSC, CSTD) plus PPE protect the handler.
- PPE: chemotherapy-rated double gloves, back-closing impermeable gown, face shield if splashing.
- Never crush, split or open oral chemotherapy.
- Excreta: contaminated at least 48 to 72 hours after injectable, up to 7 days after oral.
- Spill kit absorbs 1000 mL and has at least 2 pre-labeled waste bags.
- Clean spills from lesser to greater contamination.
- Trace (less than 3%) waste goes in the yellow chemotherapy container; sharps in a puncture-proof box.
- Vaccine refrigerator 2 to 8 degrees C; log min and max at the start of each workday.
- SDS Section 8 is PPE; Section 6 is spills.
- Never sewer hazardous pharmaceuticals; controlled drugs must be made non-retrievable.