By Tamara Dolan, RN, MSN, OCN, NurseZone editorial board member
September 24, 2010 - The use of oral chemotherapy in the treatment of cancer has increased considerably in recent years, and is projected to continue rising. Taken in the form of liquid, tablet or capsule, oral chemotherapy is frequently administered by the patient in his or her home or by non-oncology health care professionals in other non-traditional settings such as assisted living and long-term care facilities or nursing homes. As a result, some of the responsibility for safe medication administration of chemotherapy has shifted from the oncology professional to the patient or non-oncology caregiver. In addition to the potential problems related to medication errors and adherence to therapy, this new treatment model highlights the need for new practice initiatives to ensure safe handling of these hazardous drugs.
The National Institute for Occupational Safety and Health (NIOSH) defines a hazardous drug as one that may cause cancer, fetal malformations, adverse reproductive effects, organ toxicity, or genotoxicity. Once called “cytotoxic drugs,” the more comprehensive term “hazardous” is now used to better describe a category of drugs that can pose considerable health risks to workers who are exposed when manufacturing, transporting, preparing, administering, handling or disposing of these drugs. NIOSH, in their 2004 alert, warned that exposure to hazardous drugs can cause skin rashes, infertility, miscarriage, birth defects, and possibly leukemia or other cancers, making exposure avoidance critical.
Over 20 years have passed since the Occupational Safety and Health Administration (OSHA) issued its first set of guidelines related to the management of hazardous drugs in the workplace. Since that time, OSHA has issued updates to their guidelines, and other organizations, such as the Oncology Nursing Society (ONS) and the American Society of Hospital Pharmacists (ASHP), have issued similar recommendations related to safe handling.
However, much of what we know about the principles of hazardous drug safe handling is derived from practices surrounding injectable medications administered in traditional health care settings such as the hospital, clinic or physician office. For example, according Firouzan “Fred” Massoomi, Pharm.D., FASHP, studies have demonstrated that minute concentrations of hazardous drugs have been found on drug vials and packaging of injectable formulations. Although we have not yet seen studies relative to oral hazardous drugs, Massoomi recommends caregivers should assume these surfaces are contaminated.
As more oral agents are approved and used in non-traditional settings, the risk for exposure and other associated adverse effects rises. Many experts have suggested safe practices for oral chemotherapy are lacking, and recommend that consensus guidelines specific to oral chemotherapy handling in the community setting be developed.
One hospital-based clinic in North Carolina opted to address the complex practice issues related to oral chemotherapy by creating a position for a dedicated oral chemotherapy nurse. In addition to assessing the patient’s ability to safely adhere to an oral chemotherapy regimen, the nurse provides extensive education about the medication, including dose, schedule, side effects as well as other specific administration information. According to Mendy Moore, RN, MSN, OCN, this novel approach also “ensures patients are educated about safe handling.”
Oral chemotherapy drugs are not necessarily less toxic than their intravenous counterparts, as some people mistakenly believe. Therefore, safe handling procedures are critical to reduce the incidence of adverse events caused by exposure. Massoomi agrees that educating the individuals who administer hazardous drugs is critical. “(They should) know what signs and symptoms to look for in an acute exposure,” he said.
Examples of ways to reduce potential exposure to oral chemotherapy medications include the following:
• Avoid contact with the medication by transferring it from the bottle to a medicine cup and into the mouth.
• Wear gloves when contact with the medication cannot be avoided and when handling bodily fluids.
• Do not crush, break, chew or open tablets or capsules at the bedside.
• Properly dispose of unused medication by placing it in a hazardous waste container and/or returning it to the pharmacy or clinic from which it was prescribed.
• Prepare oral solutions over an absorbent, disposable mat to contain spills.
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