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Fire and Safety Requirements for Healthcare Workers

1.50 Contact Hours:
A score of 80% correct answers on a test is required to successfully complete any course and attain a certificate of completion.
Author:    Donna Thomas (RN, MSN, BSHEd)

Purpose/Goals

The purpose of this course is to update employees on the 2016 NIOSH recommendations for exposure to neoplastic and hazardous drugs, to raise employee awareness of safety, and to promote safe work practices.

Objectives

After completing this course, the learner will be able to:

  1. discuss the worker’s right to access a material safety data sheet (MSDS)
  2. discuss the 2016 NIOSH recommendations for prevention of exposure to neoplastic and hazardous drugs
  3. list three methods healthcare professionals can use to avoid back injury
  4. Using the RACE acronym, recommend specific actions to be taken during a fire to ensure the safety of employee and patients
  5. Identify 5 actions a healthcare professional should take in the presence of a potentially violent person while at work 
  6. list three chemical or physical agents that are reproductive hazards for women in the workplace

Introduction

Few workplaces are as complex as a healthcare facility. Such complex situations provide a great deal of potential health and safety hazards. When compared with the total civilian workforce, hospital workers have a greater percentage of workers’ compensation claims for sprains and strains, infectious and parasitic diseases, dermatitis, hepatitis, mental disorders, eye diseases, influenza, and toxic hepatitis.1 The list of potential hazards includes radiation, toxic chemicals, biological hazards, heat, noise, dust, and stress. The risks and exposures for blood and body fluids are important, but not included in this course. Information about the risks and exposures to blood and body fluids are available in a separate course entitled OSHA: Occupational Exposure to Blood and Body Fluids, at www.CEUFast.com.

Antineoplastic, Other Hazardous Drugs and Other Chemical Hazards

All healthcare facilities are required to have detailed information about the chemicals that are at the worksite. This information is in a standard format called a Material Safety Data Sheet (MSDS). The MSDS should be readily available to every worker. Access to the MSDS allows every worker to educate himself about the chemicals at the worksite. Chemicals may exert acute or chronic effects on workers. The effects depend on the:

  • extent (concentration and duration) of exposure
  • route of exposure
  • physical and chemical properties of the substance.

The effects exerted by a substance may also be influenced by the presence of other chemicals and physical agents or by an individual’s use of tobacco, alcohol, or drugs. The exposure dose is the amount of a substance that enters the body during the period of exposure. The substance continues to be present in the body until it is metabolized or eliminated. Although some chemicals are rapidly metabolized, others area not and may be excreted unchanged or stored in the fatty tissues (solvents), lungs (dust and fibers), bone (lead and radium), or blood (soluble gasses).

Toxic substances can enter the body through several routes, including the intact skin, the respiratory system (inhalation), the mouth (inhalation and ingestion), the eyes, and by accidental needle punctures. Inhalation and skin exposure are the most likely. Some substances can also damage the skin or eyes directly without being absorbed. Not all substances can enter the body through all routes. Inorganic lead, for example, can be inhaled or swallowed, but it does not penetrate the skin. Exposures routes for antineoplastic and other hazardous drugs are inhalation, skin absorption, ingestion, and injection.

The National Institute of Occupational Health and Safety (NIOSH) released new guidelines, in 2016, about the handling of antineoplastic and other hazardous drugs. NIOSH warns that exposure to hazardous drugs may occur to clinical and non-clinical workers in the following settings2:

  • During reconstitution of powdered or lyophilized drugs and further dilution of either the reconstituted powder or concentrated liquid forms of hazardous drugs
  • When aerosols are generated by expelling air from syringes filled with hazardous drugs or during the administration of drugs by intramuscular, subcutaneous or intravenous routes
  • When dust is generated through counting out individual uncoated oral doses and tablets from multi-dose bottles or unit-dosing uncoated tablets in a unit-dose machine, presenting a possible inhalation hazard
  • When crushing tablets to make oral liquid doses thus presenting potential inhalation and dermal exposure
  • When compounding potent powders into custom dosage capsules
  • When measurable levels of drugs are present on drug vial exteriors, work surfaces, floors, and final drug products (bottles, bags, cassettes, and syringes) and when airborne droplets of the drug are generated during reconstitution
  • When aerosols are generated during the administration of drugs, either by direct IV push or by IV infusion.
  • When handling body fluids, clothing, dressings, linens and other materials contaminated with body fluids by hospital or home health personnel working with patients treated with hazardous drugs
  • Through handling of contaminated waste generated at all steps of the preparation and administration process.
  • When specialized procedures (intraoperative intraperitoneal chemotherapy) are performed in the operating room
  • When handling unused hazardous drug waste, hazardous drug-contaminated waste, decontaminating and cleaning drug preparation or clinical areas, and transporting infectious, chemical or hazardous waste containers.
  • When removing and disposing of PPE used during the handling of hazardous drugs or waste.

NIOSH defines the healthcare workers’ responsibilities in relation to antineoplastic and other hazardous drugs as the following2:

  • Review guidance documents, Material Safety Data Sheets (MSDSs) and other information resources for hazardous drugs handled.
  • Be familiar with and be able to recognize sources of exposure to hazardous drugs.
  • Prepare these agents in a dedicated area where access is restricted to authorized personnel only.
  • Prepare these agents within a ventilated cabinet designed to protect workers and adjacent personnel from exposure and to provide product protection for all drugs that require aseptic handling.
  • Use two pairs of powder-free, disposable chemotherapy gloves with the outer one covering the gown cuff whenever there is a risk of exposure to hazardous drugs.
  • Avoid skin contact by using a disposable gown made of a low-lint and low permeability fabric. The gown should have a closed front, long sleeves and elastic or knit closed cuffs and should not be reused.
  • Wear a face shield to avoid splash incidents involving eyes, nose, or mouth when adequate engineering controls are not available.
  • Wash hands with soap and water immediately before using and after removing personal protective clothing, such as disposable gloves and gowns.
  • Use syringes and IV sets with Luer-lock fittings for preparing and administering these agents and place drug-contaminated syringes and needles in chemotherapy sharps containers for disposal.
  • When an IV line must be primed with a solution containing hazardous medication, it should be done in pharmacy.
  • When additional protection is necessary, use closed-system, drug-transfer devices, glove bags and needle-less systems within the ventilated cabinet.
  • Handle hazardous wastes and contaminated materials separately from other trash.
  • Decontaminate work areas before and after each activity with hazardous drugs and at the end of each shift.
  • Clean up spills immediately while using appropriate safety precautions and personal protective equipment (PPE) unless the spill is large enough to require an environmental services specialist.

Case Study

Ms. Marvel, a night Nursing Supervisor, was responsible for preparing any IV medications until a new night pharmacist was hired. She was instructed on how to prepare these agents within a ventilated cabinet designed to protect workers and adjacent personnel from exposure and to provide product protection for all drugs that require aseptic handling. Before preparing these medications, she had to dress the part and double glove while protecting her hands and wrists. If there was a chemical spill, she had to immediately use appropriate safety precautions and personal protective equipment unless the spill was large enough to require an environmental service specialist.

She also had to educate the ICU nurses and medical-surgical nurses on safe administration of these medications and their side effects. Mr. Marval worked with nursing educators to prepare written instructions for all units where this information was needed to prevent dangerous workplace injuries. When making hospital rounds, she made sure that the nurses knew where the MSDS information book was located and that it was up-to-date.

Back Injuries

One major source of injury to healthcare workers is musculoskeletal disorders (MSDs). In 2010, nursing aides, orderlies, and attendants had the highest rates of MSDs. There were 27,020 cases, which equates to an incidence rate (IR) of 249 per 10,000 workers, more than seven times the average for all industries; this contributed to the all-worker days-away-from-work rate of 34 per 10,000 workers. In 2010, the average incidence rate for musculoskeletal disorder (MSD) cases with days away from work increased 4 percent, while the MSD incidence rate for nursing aides, orderlies, and attendants increased 10 percent.4

These injuries are due in large part to overexertion related to repeated manual patient handling activities, often involving heavy manual lifting associated with transferring, and repositioning patients and working in extremely awkward postures.4

Nearly half of all compensation claims for hospital workers involved back injuries. The most common causes of all work-related back pain are as follow 1, 4:

  • job performance by a worker who is unfit or unaccustomed to the task,
  • postural stress, and
  • work that approaches the limit of a worker's strength

Factors that contribute to these causes of back pain are understaffing, the lack of regular training programs in proper procedures for lifting and other work motions, and inadequate general safety precautions. Written guides and programs for preventing back injury are available for all workers. The primary approach to preventing back injury involves reducing manual lifting and other load-handling tasks that are biomechanically stressful. The secondary approach is to train workers how to perform stressful tasks while minimizing the biomechanical forces on their backs, and how to maintain flexibility and strengthen the back and abdominal muscles. To prevent back injury, workers should1:

  • Use proper lifting techniques
  • Request help. When in doubt about whether a task may strain the back, a worker should request help rather than taking a chance.
  • Back exercises can be used to strengthen the back muscles and help prevent back injuries. Consult a physician or physical therapist.

Patient transfers are particularly hazardous for hospital workers. The following special points should be emphasized to prevent back injuries during transfers.

  • Communicate the plan of action to the patient and other workers to ensure that the transfer will be smooth and without sudden, unexpected moves
  • Position equipment and furniture effectively (for example, move a wheelchair next to the bed) and remove obstacles
  • Ensure good footing for the workers and patient (patients should wear slippers that provide good traction)
  • Maintain eye contact and communication with the patient. Be alert for trouble signs
  • If help is needed, request that a co-worker stand by before attempting the transfer
  • Record any problems on the patient’s chart so that other shifts will know how to cope with difficult transfers. Note the need for any special equipment, such as a lift.

Accident hazards such as wet floors, stairway obstructions, and faulty ladders should be reduced. Wet-floor hazards can be reduced by proper housekeeping procedures such as marking wet areas, cleaning up spills immediately, cleaning only one side of a passageway at a time, keeping halls and stairways clear, and providing good lighting for all halls and stairwells. Workers should be instructed to use the handrail on stairs, to avoid undue speed, and to maintain an unobstructed view of the stairs ahead of them, even if that means requesting help to manage a bulky load.

The consequences of work-related musculoskeletal injuries among nurses are substantial. Along with higher employer costs due to medical expenses, disability compensation, and litigation, nurse injuries also are costly regarding chronic pain and functional disability, absenteeism, and turnover. Approximately 20% of nurses who leave direct patient care positions do so because of risks associated with the work. Many healthcare workers, who experience pain and fatigue, may be less attentive, less productive, more susceptible to further injury, and may be more likely to affect the health and safety of others.4 Direct and indirect costs associated with only back injuries in the healthcare industry are estimated to be $20 billion annually.4

Case Study

David, a float CNA, was educated on how to use the newest lift equipment and techniques to use when transferring patients from their wheelchairs to their beds and visa-verse. He constantly encouraged the staff he worked with to ask for assistance when handling residents who were unable to help themselves or required more than one person to assist them in moving. Before using any lift-equipment, he made sure all lines and hooks were secured, and the equipment functioned safely and properly. Especially in the secure units where many of the patients have dementia or Alzheimer’s disease, he instructed the staff always to work as a cohesive team. The individual at the head of the patient was to be in charge, and they would discuss ahead of time the process they would use. Patients were told what was going to be done and why before staff transferred them. Questions were answered at patient’s level of understanding. David was always in demand!

Fire

Hospital fires and disasters are especially dangerous because workers must protect themselves and evacuate large numbers of patients. Almost one-third of hospital fires originated in patient rooms or worker quarters, with matches and smoking as the most frequent cause. Other causes are malfunctioning or misused electrical equipment such as hot plates, coffee pots, and toaster ovens.1

Deaths during hospital fires were overwhelmingly due to inhaling the toxic products of combustion rather than to direct exposure to the fire. Another obvious fire hazard is the use of oxygen in patient areas. Fires can occur in an oxygen-enriched atmosphere because of patient smoking, electrical malfunctions, and the use of flammable liquids. Procedures should be developed and strictly enforced to prevent fire hazards in patient areas where oxygen is used. When you enter a new work area, look around and find fire alarms, fire extinguishers, exit signs and oxygen cut off valves.

One way to remember fire safety is the acronym, RACE.

  • R: rescue
  • A: alarm
  • C: contain fire (if possible)
  • E: extinguish or evacuate

When rescuing anyone in immediate danger, remember to stay low. Smoke rises to the ceiling and forms a heavy, dense cloud that slowly descends. This cloud is deadly because it contains toxic gasses. Do not ever hesitate to sound the alarm with any suspicion of fire, but never yell fire. That will only create panic. Call out the facilities code for fire. Call the switchboard to report the fire and pull the fire alarm. When you call the switchboard, be sure to stay on the phone long enough to assure they got the correct information.

Healthcare units are separated by heavy fire doors that close automatically when the alarm is sounded, to keep the fire from spreading. To confine a fire, close doors, windows and all vertical openings like the laundry chute. Stuff wet towels under doors to keep smoke out. Shut off oxygen supplies if directed to do so. Usually, someone in supervision is designated to decide when to turn off oxygen supplies.

If a fire is small and confined, you may be able to extinguish it. If a patient's clothes are on fire, wrap the patient tightly in a large blanket to extinguish the flames. If a piece of equipment catches fire, pull the plug or cut the electricity as soon as possible.

If a fire cannot be extinguished and smoke, fumes or flames threaten patient safety, you may have to evacuate. Evacuate ambulatory patients first. Stay calm and give clear directions. Evacuate horizontally as long as you can. Then evaluate vertically down to a lower level. Never use an elevator to escape during a fire. A sudden loss of power could leave you trapped in the elevator.

Fire extinguishers come in different classes for use on fires of different sources. The extinguisher has small pictures on the label that help you identify the type of fire source material in which they should be used. Class A puts out fires involving ordinary combustibles. Class B extinguishers smother fires involving flammable liquids or gasses. Class C extinguishers put out fires in or near electrical equipment. Type ABC extinguishers can be used to fight all three types of fires. To use an extinguisher, pull the pin; Aim the nozzle at the base of the fire; and squeeze the trigger, while you make sweeping strokes.

Case Study

Max, an educator and environmental engineer, was responsible for ensuring that staff from all departments knew what to do in case of a fire. He worked on all shifts and reviewed the emergency plan and made sure the Charge Nurse knew he/she was responsible for turning off the oxygen in the units and assigning roles to her healthcare team. All employees had to know what the number/code was to announce a fire and its location. Exits to be taken were reinforced, and the healthcare team had to make sure they worked together as a cohesive team without causing people to panic. Staff had to demonstrate to Max that they knew where the fire alarms and extinguishers were located and had to explain how to use them. Staff had to practice using the emergency sleds located on the beds to transport disabled patients. Special mandatory hands-on workshops were held during the day. Max did this on a quarterly basis and provided documentation to the key administrators that this was completed.

Natural Disasters

Disaster plans should be prepared for natural events (e.g. tornadoes, earthquakes and hurricanes), gas leaks, and bomb threats. The plans should be written and readily available. Supervisory workers will initiate the disaster plan and designate task to workers. Workers are responsible for knowing the alarm code for a disaster and the exit routes.

Flammable and Combustible Liquids, Vapors, and Gases

A major hazard in all hospitals is the widespread use and storage of flammable and combustible liquids. Many liquids have vapors that are flammable or combustible and can be ignited by a spark from a motor, friction, or static electricity. Handling and storage directions must be followed.

Compressed gasses are under pressure and are flammable, so they must be handled with extreme care. An exploding cylinder can have the same destructive effect as a bomb. The proper handling of compressed gas cylinders requires training. Storage areas for compressed gas cylinders should be well ventilated, fireproof, and dry. Cylinders should not be stored near steam pipes, hot water pipes, boilers, highly flammable solvents, combustible wastes, unprotected electrical connections, open flames, or other potential sources of heat or ignition. Cylinders should be properly labeled. The valve protection cap should not be removed until the cylinder is secured and ready for use.

Compressed gasses used in hospitals include acetylene, ammonia, anesthetic gasses, argon, chlorine, ethylene oxide, helium, hydrogen, methyl chloride, nitrogen, and sulfur dioxide. Acetylene, ethylene oxide, methyl chloride, and hydrogen are flammable, as are the anesthetic agents, cyclopropane, diethyl ether, ethyl chloride, and ethylene. Although oxygen and nitrous oxide are labeled as nonflammable, they are oxidizing gasses that will aid combustion.

Electrical Equipment

Violations of standards governing the use of electrical equipment are the most frequently cited causes of electrical fires. Thorough electrical maintenance records should be kept, and considerable effort should be devoted to electrical safety, particularly in areas where patient care is involved. Equipment and appliances that are frequently ungrounded or incorrectly grounded include1:

  • Three-wire plugs attached to two-wire cords
  • Grounding prongs that are bent or cut off
  • Ungrounded appliances resting on metal surfaces
  • Extension cords with improper grounding
  • Cords molded to plugs that are not properly wired
  • Ungrounded, multiple-plug spiders that are often found in office areas and at nurses' stations
  • Personal electrical appliances brought by the workers from home (radios, coffee pots, fans, electric heaters) that are not grounded, have frayed cords, poor insulation, or are otherwise in poor repair.

Violence

Workplace violence is a serious concern for the approximately 15 million health care workers in the United States. OSHA is the federal agency responsible for protecting the safety and health of the nation's workers, although states may assume responsibility under an OSHA-approved plan. OSHA does not require employers to implement workplace violence prevention programs, but it provides voluntary guidelines and may cite employers for failing to provide a workplace free from recognized serious hazards.5

The circumstances of hospital violence differ from the circumstances of workplace violence in general. In other workplaces such as convenience stores and taxicabs, violence most often relates to robbery. Violence in hospitals usually results from patients and occasionally from their family members who feel frustrated, vulnerable, and out of control. Common risk factors for hospital violence include the following6:

  • Working directly with volatile people, especially if they are under the influence of drugs or alcohol or have a history of violence or certain psychotic diagnoses
  • Working when understaffed-especially during meal times and visiting hours
  • Transporting patients
  • Long waits for service
  • Overcrowded, uncomfortable waiting rooms
  • Working alone
  • Poor environmental design
  • Inadequate security
  • Lack of staff training and policies for preventing and managing crises with potentially volatile patients
  • Drug and alcohol abuse
  • Access to firearms
  • Unrestricted movement of the public
  • Poorly lit corridors, rooms, parking lots, and other areas

Violence may occur anywhere in the hospital, but it is most frequent in psychiatric wards, emergency rooms, waiting rooms, and geriatric units.4 Studies indicate that violence often takes place during times of high activity and interaction with patients. Assaults may occur when service is denied, when a patient is involuntarily admitted, or when a healthcare worker attempts to set limits on eating, drinking, or tobacco or alcohol use.4 Patients with a condition that causes confusion and impaired judgment are more likely to become violent than a patient with normal mentation. Confusion and impaired judgment may be caused by neurologic conditions, seizures, hypoglycemia, or dementia.7

Watch for signals that may be associated with impending violence4:

  • Verbally expressed anger and frustration
  • Body language such as threatening gestures
  • Signs of drug or alcohol use

Note how your co-workers behave. If a colleague’s demeanor or behavior has changed for the worse, notify your manager. For example, slamming equipment around is red-flag behavior. Learn from their history. If a patient has a history of violent behavior (such as acting combative in the ambulance or waiting room), prepare yourself for potentially violent behavior and warn others who are caring for him. Let security know if you feel threatened or if you find or suspect that he's carrying a weapon. Notify your nursing supervisor, manager, and hospital security or police if you suspect a patient is going to be violent. Keep your patient informed. Help relieve his tension and anxiety by keeping him informed about when he'll be examined or treated and what's going on.7

Be alert6:

  • Evaluate each situation for potential violence when you enter a room or begin to relate to a patient or visitor.
  • Be vigilant throughout the encounter.
  • Do not isolate yourself with a potentially violent person.
  • Plan your exit.
  • Watch your surroundings.

Always keep an open path for exiting. Do not let the potentially violent person stand between you and the door. When you're with an upset patient or co-worker, avoid areas of the room that do not have an accessible exit. If you're going to an isolated part of your facility, let others know where you're going and when you expect to return. Consider asking for an escort. Observe your surroundings and note anyone who is not wearing staff ID and is lingering where he should not. Ask politely if you can help him and notify security if you aren't satisfied with his answer. If you'd rather not approach someone, call security and provide a full description. Evaluate the way you wear equipment to be sure it cannot be used as a weapon against you. For example, consider that a stethoscope or ID badge without a breakaway necklace can be used to choke you. Carry your stethoscope in a pocket and use an ID badge necklace that has a breakaway feature. If you wear a necktie, opt for a clip-on style. If your hair is long, wear it in a way that's not easy to pull, and do not wear dangling jewelry.7

In the presence of a potentially violent person7:

Do

  • Plan a clear exit route.
  • Keep 5 to 7 feet between you and him. Never turn your back on him or let him get between you and the exit.
  • Keep your voice calm and quiet.
  • Acknowledge that he has a right to his feelings.
  • Assume that he has a valid concern, and address it.
  • Try to meet reasonable demands.
  • Offer alternatives when possible. For example, tell an angry patient that although he cannot order take-out pizza, you'll see if you can get him an early dinner. Tell an angry colleague that you see that she's angry and that you'd like to work with her and your manager to resolve the situation.
  • Call for backup or security if a situation grows increasingly tense.

Do not

  • Do not ignore the agitated person or avoid him.
  • Do not threaten or demand obedience.
  • Do not argue or become defensive or judgmental.
  • Do not laugh, move suddenly, make threatening gestures, or invade his personal space.
  • Do not try to handle a dangerous situation alone. Call security or initiate your facility's violence prevention protocol.
  • Ensure that he has access to bathrooms, a phone, TV, and something to read.
  • Track equipment. Return it to its rightful place. When you take an item into a patient’s room, dispose of it properly or take it with you when you leave.

Take these steps if you cannot defuse the situation quickly6:

  • Remove yourself from the situation.
  • Call security for help.
  • Report any violent incidents to your management.

In the presence of a weapon, maintain behavior that helps diffuse anger6:

  • Present a calm, caring attitude.
  • Do not match the threats.
  • Do not give orders.
  • Acknowledge the person's feelings (for example, "I know you are frustrated").
  • Avoid any behavior that may be interpreted as aggressive (for example, moving rapidly, getting too close, touching, or speaking loudly).

Reproductive Hazards

Up to 4 million women employed in hospitals may be exposed to reproductive hazards. However, there is no clear evidence that exposure conditions in hospitals have resulted in an excess rate of birth defects among the offspring of hospital workers.8 Studies do support more general associations between employment in hospitals or laboratories and an increased risk of adverse reproductive effects, primarily spontaneous abortion. Workers with immunity through vaccinations or earlier exposures are not generally at risk for diseases such as hepatitis B, human parvovirus B19, German measles, or chicken pox. But pregnant workers without prior immunity should avoid contact with infected children or adults. Workers should also use good hygienic practices such as frequent handwashing to prevent the spread of infectious diseases and universal precautions.8 In addition to many of these drugs being cytotoxic, the majority are hazardous to males or females who are actively trying to conceive, women who are pregnant or may become pregnant, and women who are breastfeeding, because they may be present in breast milk. These drugs represent an occupational hazard to healthcare workers and should always be handled with the use of recommended engineering controls and personal protective equipment (PPE), regardless of their formulation (IV [intravenous], SC [subcutaneous], topical, tablet, or capsule). Unopened, intact tablets and capsules may not pose the same degree of occupational exposure risk as injectable drugs, which usually require extensive preparation. Cutting, crushing, or otherwise manipulating tablets and capsules will increase the risk of exposure to workers.8

The following tables outline the hazards and effects.8(p1)

 Table 1: Chemical and physical agents that are reproductive hazards for women in the workplace
Agent Observed effects Potentially exposed workers
Cancer treatment drugs (e.g., methotrexate) Infertility, miscarriage, birth defects, low birth weight Healthcare workers, pharmacists
Certain ethylene glycol ethers such as
2-ethoxyethanol (2EE) and
2-methoxyethanol (2ME)
Miscarriages Electronic and semiconductor workers
Carbon disulfide (CS2) Menstrual cycle changes Viscose rayon workers
Lead Infertility, miscarriage, low birth weight,
developmental
disorders
Battery makers,
solderers, welders, radiator repairers, bridge repainters,
firing range workers, home remodelers
Ionizing radiation (e.g., X-rays and gamma rays) Infertility, miscarriage, birth defects, low birth weight, developmental disorders, childhood cancers Healthcare workers, dental personnel, atomic workers
Strenuous physical
labor (e.g., prolonged standing, heavy lifting)
Miscarriage late in pregnancy, premature delivery Many types of workers
Table 2: Chemical and physical agents that are reproductive hazards for women in the workplace
Agent Observed effects Potentially exposed workers Preventive measures
Cytomegalo-
virus
(CMV)
Birth defects, low birth weight, developmental disorders Healthcare workers, workers in contact with infants and children Good hygienic practices such as handwashing
Hepatitis B virus Low birth weight Healthcare workers Vaccination
Human
immuno-deficiency
virus (HIV)
Low birth weight, childhood
cancer
Healthcare workers Practice universal precautions
Human
parvovirus B19
Miscarriage Healthcare
workers, workers in contact with infants and children
Good hygienic practices such as handwashing
Rubella
(German
measles)
Birth defects, low birth weight Healthcare workers, workers in contact with infants and children Vaccination before pregnancy if no prior
immunity
Toxoplas-mosis Miscarriage, birth defects,
developmental disorders
Animal care workers,
veterinarians
Good hygiene practices such as handwashing
Varicella-
zoster virus (chicken pox)
Birth defects, low birth weight Healthcare workers, workers in contact with infants
and children
Vaccination before pregnancy if no prior
immunity

Workers with immunity through vaccinations or earlier exposures are not generally at risk for diseases such as hepatitis B, human parvovirus B19, German measles, or chicken pox. But pregnant workers without prior immunity should avoid contact with infected children or adults. Workers should also use good hygienic practices such as frequent handwashing to prevent the spread of infectious diseases and universal precautions.8

‡BCG, although classified as a vaccine, is used in the treatment of certain cancers. BCG should be prepared with aseptic techniques. Parenteral drugs should not be prepared in areas where BCG has been prepared to prevent cross-contamination. A separate area for the preparation of BCG suspension is recommended. All equipment, supplies, and receptacles in contact with BCG should be handled and disposed of as biohazardous. If preparation cannot be performed in a containment device, then respiratory protection, gloves, and a gown should be worn to avoid inhalation or contact with BCG organisms.

NIOSH performs a hazard identification for each of the drugs listed based on its criteria as described above. The actual risk to healthcare workers depends on the toxicity of the drugs, how the drugs can enter the body (e.g., dermal, inhalation, or ingestion), and how the drugs are handled.  Also of concern is how the drugs are manipulated, how often they are handled, and the exposure controls in place, such as the type of engineering controls and personal protective equipment (PPE). For example:

  • Dispensing a single tablet to a patient may pose a relatively low risk to the healthcare worker. A single pair of gloves may be adequate.
  • Repeatedly counting, cutting, or crushing tablets may pose a higher risk for worker exposure than dispensing a single tablet and contamination to the workplace if exposure controls are not in place.
  • If a containment device such as a BSC (Class II biological safety cabinet) or CACI (compounding aseptic containment isolator) is not available, then double gloves, a protective gown, respiratory protection, and a disposable pad to protect the work surface should be used.
  • Preparing several intravenous doses of an antineoplastic drug typically poses a higher potential risk to the worker. In addition to double gloving and a protective gown, an engineering control such as a BSC or CACI, possibly supplemented with a CSTD (closed system drug transfer device), is necessary to protect the drug, environment, and healthcare worker.

Group 1: Antineoplastic drugs, including those with the manufacturer’s safe-handling guidance (MSHG). Abbreviations: AHFS = American Hospital Formulary Service; MRHD = maximum recommended human dose.

     NIOSH’s updated list of the newest 2016 drugs are noted below:

The 2016 drugs listed below in Table 1 meet one or more of the NIOSH criteria for a hazardous drug. In addition to many of these drugs being cytotoxic, the majority are hazardous to males or females who are actively trying to conceive, women who are pregnant or may become pregnant, and women who are breastfeeding, because they may be present in breast milk. These drugs represent an occupational hazard to healthcare workers and should always be handled with the use of recommended engineering controls and personal protective equipment (PPE), regardless of their formulation (IV [intravenous], SC [subcutaneous], topical, tablet, or capsule). Unopened, intact tablets and capsules may not pose the same degree of occupational exposure risk as injectable drugs, which usually require extensive preparation. Cutting, crushing, or otherwise manipulating tablets and capsules will increase the risk of exposure to workers. The manufacturer’s safe-handling guidance (MSHG) is typically in Section 16 of the DPI. See Table 5 for safe-handling recommendations.2

Table 3: Group 1 - Anineoplastic drugs, including those with the manufacturer's safe-handling guidance (MSHG) 2016 added drugs
Drug AHFS classification MSHG Supplemental information Links
afatinib* 10:00 antineoplastic agents
 
Special warnings on contraception for females while taking and 2 weeks post-treatment; FDA Pregnancy Category D DailyMed; DrugBank
axitinib 10:00 antineoplastic agents   Teratogenic, embryotoxic and fetotoxic in mice at exposures lower than human exposures; FDA Pregnancy category D DailyMed; DrugBank
belinostat 10:00 antineoplastic agents yes May cause teratogenicity and/or embryo-fetal lethality because it is a genotoxic drug and targets actively dividing cells; FDA Pregnancy Category D DailyMed; DrugBank
bosutinib 10:00 antineoplastic agents  

FDA Pregnancy

Category D

DailyMed; DrugBank
cabozantinib 10:00 antineoplastic agents  

agents

Embryolethal in rats at exposures below the recommended human dose; FDA Pregnancy category D
DailyMed; DrugBank
carfilzomib 10:00 antineoplastic agents  

agents

Special warnings on contraception while taking and 2 weeks post- treatment; FDA Pregnancy category D
DailyMed; DrugBank
dabrafenib 10:00 antineoplastic agents   Special warnings on contraception for females while taking and 2 weeks post-treatment; FDA Pregnancy Category D DailyMed; DrugBank
enzalutamide 10:00 antineoplastic agents   Embryo-fetal toxicity in mice at exposures that were lower than in patients receiving the recommended dose; FDA Pregnancy Category X DailyMed; DrugBank
histrelin
 
10:00 antineoplastic agents   Can cause fetal harm when administered to a pregnant patient, with the possibility of spontaneous abortion; FDA Pregnancy Category X DailyMed; DrugBank
ixazomib 10:00 antineoplastic agents yes Male and female patients of childbearing potential must use effective contraceptive measures during and for 3 months following treatment DailyMed; DrugBank
panobinostat 10:00 antineoplastic agents yes Special warnings on contraception for females while taking and 1 month post-treatment DailyMed; DrugBank
pertuzumab 10:00 antineoplastic agents   Black Box warning on embryo-fetal death and birth defects; FDA Pregnancy Category D

DailyMed;

DrugBank

pomalidomide 10:00 antineoplastic agents yes Females of reproductive potential must use two forms of contraception or continuously abstain from heterosexual sex during and for 4 weeks after stopping treatment; FDA Pregnancy Category X


DailyMed;

DrugBank

ponatinib 10:00 antineoplastic agents   FDA Pregnancy Category D

DailyMed;

DrugBank

regorafenib 10:00 antineoplastic agents   Black Box warning on severe and sometimes fatal hepatotoxicity; total loss of pregnancy at doses lower than recommended human dose; FDA Pregnancy Category D

DailyMed;

DrugBank

trametinib 10:00 antineoplastic agents   Embryotoxic and abortifacient at doses less than recommended human dose; FDA Pregnancy Category D

DailyMed;

DrugBank

trifluridine/tipiracil (combination only) 10:00 antineoplastic agents yes Embryo-fetal lethality and embryo-fetal toxicity at doses lower than or similar to exposures at the recommended human dose

DailyMed;

DrugBank

vismodegib 10:00 antineoplastic agents   Black Box warning on embryo-fetal death or severe birth defects; recommend effective contraception for females during therapy and for 7 months after treatment; present in semen; no sperm donation during and 3 months posttreatment; FDA Pregnancy Category D

DailyMed;

DrugBank

ziv-aflibercept 10:00 antineoplastic agents   Embryotoxic and teratogenic in rabbits at exposure levels lower than human exposures at the recommended dose, with increased incidences of external, visceral, and skeletal fetal malformations; FDA Pregnancy Category C

DailyMed;

DrugBank

Table 4: Gourp 2- Non-antineoplastic drugs that meet one or more of the NIOSH criteria for a hazardous drug, including those with the manufacturer's safe-handling guidance (MSHG)
Drug AHFS classification MSHG Supplemental information Links
methimazole‡ 68:36:08 antithyroid agents   Appears in human breast milk; FDA Pregnancy Category D

DailyMed;

DrugBank

mipomersen 24:06:92 antilipemic agents, miscellaneous   Black Box warning on hepatotoxicity; FDA Pregnancy Category B

DailyMed;

DrugBank

ospemifene 68:16:12 estrogen agonists-antagonists   Black Box warning on increased risk of endometrial cancer in certain populations; risk of adverse outcomes during pregnancy and labor; FDA Pregnancy Category X

DailyMed;

DrugBank

paliperidone 28:16:08:04 atypical antipsychotics   Metabolite of risperidone; excreted in human breast milk; FDA Pregnancy Category

DailyMed;

DrugBank

teriflunomide 92:20 immunomodulatory agents   Black Box warning on severe hepatotoxicity and teratogenicity, including major birth defects; FDA Pregnancy Category X

DailyMed;

DrugBank


tofacitinib

92:36 disease modifying antirheumatic drugs
 
Black Box warning for lymphoma and other malignancies; FDA Pregnancy Category C


DailyMed;

DrugBank

Table 5: Group 3 -Non-antineoplastic drugs that primarily have adverse reproductive effects
Drug AHFS classification MSHG Supplemental information Links
clomiphene* 68:16:12 estrogen agonist-antagonists
 
FDA Pregnancy Category X

DailyMed;

DrugBank

eslicarbazepine 28:12:92 anticonvulsants, miscellaneous   Fetal malformations, fetal growth retardation, embryolethality, and reduced body weights observed in animal studies; excreted in human breast milk; FDA Pregnancy Category C

DailyMed;

DrugBank

lomitapide 24:06:92 antilipemic agents, miscellaneous   FDA Pregnancy Category X

DailyMed;

DrugBank

macitentan 48:48 vasodilating agents   Black Box warning for embryofetal toxicity; special warnings on contraception for females while taking and 1 month post-treatment; FDA Pregnancy Category X

DailyMed:

DrugBank

pamidronate 92:24 bone resorption inhibitors   Embryo-fetal toxicities at doses below the recommended human dose; FDA Pregnancy Category D

DailyMed;

DrugBank

pasireotide 68:29:04 somostatin agonists   Increased implantation loss and decreased viable fetuses, corpora lutea, and implantation sites at doses less than the human recommended dose; FDA Pregnancy Category C

DailyMed;

DrugBank

peginesatide 20:16 hematopoietic agents   Adverse embryo-fetal effects, including reduced fetal weight, increased resorption, embryofetal lethality, and cleft palate, observed in doses below the recommended human dose; FDA Pregnancy Category C

DailyMed;

DrugBank

riociguat 48:48 vasodilating agents   Exclude pregnancy before the start of treatment, monthly during treatment, and 1 month after stopping treatment; FDA Pregnancy Category X

DailyMed;

DrugBank

temazepam 28:24:08 benzodiazepines   Increased risk of congenital malformations associated with treatment during the first trimester of pregnancy; FDA Pregnancy Category X

DailyMed;

DrugBank

Table 5: Would list drugs that were deleted from the 2014 NIOSH hazardous drug list for the 2016 update; however, there are no deletions to report
Table 6: Personal Protective Equipment (PPE) and engineering controls
for working with hazardous drugs in healthcare settings*
Formulation Activity Double chemo-therapy gloves Protective gown Eye/face protection Respiratory protection Ventilated engineering control
All types of hazardous drugs Receiving, unpacking, and placing in storage No (single glove can be used, unless spills occur) Yes, when spills and leaks occur No Yes, when spills and leaks occur No
Intact tablet or capsule Administration from unit-dose package No (single glove can be used) No No No N/A
Tablets or Capsules Cutting, crushing, or manipulating tablets or capsules; handling uncoated tablets

Yes

Yes

No

Yes, if not done in a control device

Yes

Administration

No (single glove can be used) No

Yes, if vomit or potential to spit up

No

N/A

Oral liquid drug or feeding tube Receiving, unpacking, and placing in storage No (single glove can be used, unless spills occur) Yes, when spills and leaks occur No Yes, when spills and leaks occur No
Topical drug

Compounding

Yes

Yes

Yes, if not done in a control device

Yes, if not done in a control device

Yes†, BSC or CACI (Note: carmustine and mustargen are volatile)

Administration

Yes  Yes Yes, if liquid that could splash‡ Yes, if inhalation potential N/A
Subcutaneous/ intra-muscular injection from a vial

Preparation (withdrawing from vial)

Yes

Yes

Yes, if not done in a control device

Yes, if not done in a control device

Yes, BSC or CACI

Administration

Yes

Yes

Yes, if liquid that could splash‡ No

N/A


Withdrawing and/or mixing intravenous or intramuscular solution from a vial or ampoule

Compounding

Yes

Yes

No

No

BSC or CACI; use of CSTD re-commended

Administration of prepared solution

Yes

Yes


Yes; if liquid that could splash

No

N/A; CSTD required per USP 800 if the dosage form allows


Solution for irrigation

Compounding

Yes

Yes

Yes, if not done in a control device

Yes, if not done in a control device

Yes, BSC or CACI; use of CSTD re-commended

Administration (bladder, HIPEC, limb perfusion, etc.)

Yes

Yes

Yes

Yes

N/A


Powder/solution for inhalation/ aerosol treatment

Compounding

Yes

Yes

Yes, if not done in a control device

Yes, if not done in a control device

Yes, BSC or CACI; use of CSTD recommended

Aerosol administration

Yes

Yes

Yes

Yes

Yes, when applicable


Administration

Yes

Yes

Yes, if liquid that could splash‡ 

Yes, if inhalation potential


N/A
Drugs and metabolites in body fluids Disposal and cleaning Yes Yes Yes, if liquid that could splash Yes, if inhalation potential N/A
Drug-contaminated waste Disposal and cleaning Yes Yes Yes, if liquid that could splash Yes, if inhalation potential N/A
Spills Cleaning Yes Yes Yes Yes N/A

Dermatological Hazards

Skin injuries and diseases account for a large proportion of all occupational injuries and diseases. Skin injuries in the hospital environment include cuts, lacerations, punctures, abrasions, and burns. Skin diseases and conditions of hospital workers include dermatitis, allergic sensitization, infections such as herpes, and skin cancer. Chemicals can directly irritate the skin or cause an allergic sensitization. Physical agents can also damage the skin, and skin that has been chemically or physically damaged is vulnerable to infection.

The most common, and often the most easily preventable of all job-related health problems, are skin reactions (dermatitis.) The skin is the natural defense system of the body: it has a rough, waxy coating, a layer of protein, keratin, and an outer layer of dead cells to help prevent chemicals from penetrating the tissues and being absorbed into the blood.

Many chemicals cause irritation on contact with the skin, irritant contact dermatitis, by dissolving the protective fats or keratin protein layer, dehydrating the skin, or killing skin cells. Symptoms of this kind of irritation are red, itchy, peeling, dry, or cracking skin. Some chemicals are not irritants under normal conditions, but they will irritate skin that has already been damaged by sunburn, scratching, prolonged soaking, or other means. Tars, oils, and solvents can plug the skin pores and hair follicles, causing blackheads, pimples, and folliculitis.

Some persons become sensitized to chemicals days, months, or even years after their first exposure. This allergic reaction does not occur in every worker who contacts the chemical. Symptoms are red, itchy, and blistering skin, like a poison oak or ivy reaction, and may be much more severe than the direct irritation described in the previous subsection.

The association between basal and squamous cell carcinomas and ultraviolet radiation has been well established. The association between skin cancer and exposure to other agents is less well documented, but ionizing radiation and antineoplastic drugs have been implicated. Other evidence indicates that malignant transformation of cells damaged by chronic allergic contact dermatitis may occur.3

The skin can be damaged by a variety of microorganisms, including bacteria, fungi, viruses, and parasites. Herpes simplex is the most common dermatologic infection among dentists, physicians, and nurses.

Relatively simple precautions can considerably reduce skin hazards. Effective measures include work practices and engineering controls that limit solvent exposure, the use of personal protective equipment, substitution of less irritating chemicals, use of non-powdered gloves, and the institution of a good hygiene program.

Stress

Job stress refers to the harmful physical and emotional responses that occur when the requirements of the job do not match the capabilities, resources, or needs of the worker. Job stress can lead to poor health and even injury.2 Hospital work often requires coping with some of the most stressful situations found in any workplace. Hospital workers must deal with life-threatening injuries and illnesses complicated by complex hierarchies of authority and skills, dependent and demanding patients, and patient deaths; all of these contribute to stress. Other important stress factors include job specialization, discrimination, concerns about money, lack of autonomy, work schedules, ergonomic factors, and technological changes. The increasing size and bureaucracy of many hospitals may depersonalize the environment and leave many workers feeling isolated, fatigued, angry, powerless and frustrated. These feelings may be expressed as apathy, loss of self-confidence, withdrawal, or absenteeism. Failure to recognize and treat the sources of stress results in workers who suffer burnout. Factors commonly mentioned as causes of stress by all categories of hospital workers are3:

  • Understaffing
  • Role conflict and ambiguity
  • Inadequate resources
  • Working in unfamiliar areas
  • Excessive noise
  • Lack of control (influence, power) and participation in planning and decision making
  • Lack of administrative rewards
  • Under-utilization of talents and abilities
  • Rotating shift work
  • Exposure to toxic substances
  • Exposure to infectious patients

Stress has been associated with loss of appetite, ulcers, mental disorder, migraines, difficulty in sleeping emotional instability, disruption of social and family life, and the increased use of cigarettes, alcohol, and drugs. Stress can also affect worker attitudes and behavior. Some frequently reported consequences of stress among hospital workers are difficulties in communicating with very ill patients, maintaining pleasant relations with coworkers, and judging the seriousness of a potential emergency.

Conclusion

Many healthcare workers are constantly having to deal with exposures to neoplastic and hazardous drugs. Every year new drugs are developed and each has certain side effects. Fortunately, organizations such as NIOSH, CDC, and DHHS are constantly updating important information telling us how to be safe along with side effects of new chemical agents. Healthcare workers in all departments need to know where their MSDS book is located and have easy access to it. Educators must constantly up-date their safety manuals, educate works on all shifts and in all departments.

In todays’ volatile world healthcare workers and others need to stay informed of how to handle fires, and to be prepared for disasters both man-made and natural. Knowing how to use equipment that can prevent injuries along with practicing using this equipment is imperative.

Workplace violence is everybody’s concern. The key to success is to learn to listen effectively, know when to speak and what to say, respect everybody’s personal distance, and show genuine concern for all those you are in contact with. People need to feel valued and appreciated and know what the consequences are for their actions.

Administrators have the responsibility of making sure healthcare workers are protected from injuries while at work and enforce the consequences when a worker is physically or mentally abused by a patient, relative, or co-worker. Healthcare facilities should be safe havens for all!

References

  1. DHHS. Guideline for protecting the safety and health of healthcare workers. Published 1998. Accessed October 15, 2016.
  2. CDC/NIOSH. Risks of Workplace Violence in Health Care Settings.  Published 2016.  Accessed October 16, 2016.

CDC/NIOSH. NIOSH list of antineoplastic and other hazardous drugs in healthcare settings. Published 2016. (Visit Source). Accessed October 16, 2016
CDC/NIOSH. Staying safe at work. Published 2016. Accessed October 14, 2016

NIOSH Research Rounds. Medical research links stress, including work. Published April, 2016. Accessed October 13, 2016.

  1. NIOSH. Stress at work. Published 1999. The CDC. Accessed August 15, 2004
  2. DHHS. (2016)
  3. NIOSH Research Rounds (April, 2016). Medical research links stress, including work. Published April, 2016. Accessed October 13, 2016.
  4. DHHS/CDC. Violence: Occupational hazards in hospitals. DHHS (NIOSH) publication no. 2002-101. Accessed October 14, 2016.
  5. Doody, L. (2003). Hospital nursing defusing workplace violence. Nursing 33(8) 32. ProQuest. Accessed October 14, 2016.
  6. NIOSH. (2002). The effects of workplace hazards on female reproductive health. Published 2002. The CDC Accessed August 15, 2004

CDC. Environmental Health; Workplace Safety. Published 2016. Accessed October 16, 2016.

OSHA. Controlling occupational exposure to hazardous drugs. Published 2016. (Visit Source). Accessed October 10, 2016.


This course is applicable for the following professions:

Advanced Registered Nurse Practitioner (ARNP), Certified Nursing Assistant (CNA), Certified Registered Nurse Anesthetist (CRNA), Clinical Nurse Specialist (CNS), Home Health Aid (HHA), Licensed Practical Nurse (LPN), Licensed Vocational Nurses (LVN), Midwife (MW), Registered Nurse (RN), Respiratory Therapist (RT)

Topics:

Administration & Leadership, CPD: Preserve Safety, Legal & Regulatory


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