Dispensing Hazardous Drugs

VTH Policy: PharmH654

Implementation Date: 11/2021

Date of Last Revision: 6/24/2023

Next Review Due: 6/23/2026


Reviewed by VTH Administrative Team: 11/2021

Reviewed by VTH Board: N/A


Reviewed & Approved by Hospital Director: 11/2021 

Reviewed by Biosecurity Subcommittee: N/A

Subject to modification by the VTH Director without approval.


The intent of this policy is to define the process of dispensing hazardous drugs safely within the VTH. This is applicable to all personnel involved in the dispensation of hazardous drugs.

Personnel must don appropriate PPE and use necessary and dedicated devices and equipment for hazardous drug preparation and administration. Preparation and dispensing of hazardous drugs must be handled in designated areas designed for HD tasks and administration must occur in specified areas by appropriate personnel.


  1. It must be assumed that hazardous drugs may have residue present on drug containers, individual dosage units, outer bags/containers, work surfaces, and/or floors. Other equipment (e.g., IV lines) that are used in the dispensing of hazardous drugs must also be assumed to have residue present.

  2. The counting or repackaging of hazardous drugs must be completed carefully and utilize dedicated, clean equipment.

  3. The compounding of hazardous drugs must be completed using dedicated equipment that is not used for preparing non-sterile compounds.

Procedure (if applicable)

  1. Dedicated “chemotherapy” counting trays and spatulas must be used to count loose HD tablets and capsules.
    1. Group 1 NIOSH drugs (chemotherapeutics) must NOT be split, crushed, or opened
    2. Group 2 and 3 NIOSH drugs should be recommended to avoid splitting, crushing, or opening based upon potential hazardous
    3. If crushing of hazardous drugs is required for a compounded medication, a plastic pouch should be utilized to contain any dust or particles generated.

  2. Countertops, chemotherapy dedicated trays, and spatulas must be cleaned after each use with an appropriate cleaning solution.

  3. Counting of non-coated tablets or capsules that have visual evidence of hazardous drug powder residue on them, or compounding HD oral solutions must be performed using safety strategies, such as donning a N95 mask and chemotherapy gloves. In the VTH Dispensary, we do not compound non-sterile hazardous drugs from bulk chemical or Class 1 HDs.

  4. Tablet and capsule forms of the antineoplastics HDs must not be placed in an automatic counting machine.

  5. Environmental sampling for HD residue should take place in dispensing area at least every 6 months.

  6. Hazardous drugs must be administered safely using protective medical devices and techniques, such as using a closed system transfer device.
    1. Chemotherapeutics must be dispensed in chemotherapy bags and with appropriate auxiliary labels (if being sent home)
      1. Chemotherapeutic, reproductive toxicity, wear gloves and wash hands
    2. Hazardous drugs must be dispensed with appropriate auxiliary labels
      1. Reproductive toxicity, wear gloves and wash hands
  7. Designated staff should be prepared to use a spill kit if necessary (e.g., if spill is more than 5ml or 5gm).
    1.  Spills less than 5ml or 5gm should be cleaned up immediately using appropriate PPE, including disposable chemotherapeutic gowns, two pairs of chemotherapy-approved gloves, and eye protection. See Spill Control SOP for further instructions.

  8. Equipment (such as tubing and needles) and packaging materials must be disposed of properly, such as in HD waste containers after administration.

  9. After use, PPE must be removed and disposed of in a waste container approved for trace-contaminated HD waste at the site of drug administration.

Definitions (if applicable)

NIOSH : National Institute of Occupational Health and Safety

HD : Hazardous Drug

PPE : Personal Protective Equipment

SOP : Standard Operating Procedure

Veterinary Teaching Hospital (VTH): The collective clinical services of the Large Animal Clinic, Midwest Equine, the Small Animal Clinic, and the Veterinary Medicine South Clinic.


KeywordsDispensing, hazardous, administering   Doc ID129577
OwnerJenny C.GroupUofI College of Veterinary Medicine Teaching Hospital
Created2023-07-06 13:47 CDTUpdated2023-07-06 13:50 CDT
SitesUniversity of Illinois College of Veterinary Medicine Teaching Hospital
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