Hazardous Communication Program
VTH Policy: PharmH656
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 outline and provide safety standards implemented in compliance with the OSHA Hazard Communication Standard to provide appropriate protective measures for all individuals handling hazardous materials.
SOPs will be developed to ensure effective training for the appropriate handling of hazardous drugs (e.g., labeling, transporting, storage, disposal, dispensing, and administration). The individual will refer to the specific SOP, SDS, and/or GHS, when necessary. The Medication Dispensary will provide employee training when requested or required by an SOP and will evaluate Hazard Communication Plan every fiscal year.
The Medication Dispensary will have the following easily accessible to personnel:
- Hazardous drugs and chemicals stocked in the Medication Dispensary
- Safety Data Sheets (SDSs) for all HDs and chemicals
- Proper labeling that is compliant with the GHS system
- Appropriate PPE with enough inventory in stock
1. Hazardous Drug / Chemical Inventory
The Medication Dispensary will compile, maintain, and update, as needed, a list of hazardous drugs and chemicals that are stocked. Inventory will list the chemical name (or other product identifier on appropriate SDS) and name of the manufacturer. It will be updated when a new product is introduced and will be communicated to the Medication Dispensary staff. If the new product poses potential hazards that have not previously been present, affected employees shall receive training on those new hazards before using it. A new product may also require a hazard assessment.
2. Safety Data Sheets (SDS)
An SDS must be obtained for each hazardous product before it can be used. The SDS will be readily available during all work shifts to all employees working in the area where hazardous chemicals are present. Electronic access as an alternative to paper copies is permitted as long as no barriers to immediate employee access are created. When a substance is no longer actively used or purchased, its SDS shall be removed from the active file and placed in a file for inactive substances. These shall be maintained for 30 years.
Original containers for HDs that are received from manufacturers or distributors will be required to have container labels compliant with the GHS system.
- Secondary Containers: If a chemical is poured from an original container into another container system (e.g., alcohol, chlorhexidine), the secondary container will be labeled with the following at a minimum (1) name of the chemical and (2) hazard warnings as on the original container.
4. Personal Protective Equipment (PPE) and Hazard Drug Risk Acknowledgement
The Medication Dispensary Unit Head (Pharmacy Coordinator) will be responsible for providing required PPE at no cost to employees and will ensure that PPE is properly cleaned and maintained.
- The Pharmacy Coordinator will enforce the requirement that affected employees must use appropriate PPE and that PEE properly fits each employee.
- Employees working with hazardous drugs will all be required to review and sign Hazard Drug Risk Acknowledgement Form.
- Includes all VTH Staff and 4th-year students.
5. Employee Training
All employees shall receive training on hazardous drugs/chemicals in their work area and whenever a new chemical hazard is introduced. Training will be provided during work hours at no cost to the employee. Training will be conducted by either the Biosafety Committee or the Medication Dispensary depending on the drug/chemical.
- Training will include the requirements of the Hazard Communication Standards, how to read and interpret an SDS, and GHS classification and labeling.
- Employees will be trained on the location of SDSs, workplace labeling system, proper use of PPE, measures to be taken to protect themselves from hazards, and methods and observation techniques to determine the presence or release of hazardous chemicals if applicable.
- Once training has been completed, each employee shall demonstrate an understanding of the training specified above, as well as the ability to use PPE properly, before being allowed to perform work requirements with the use of PPE.
Employees will have the following responsibility for compliance:
- Be familiar with the Hazard Communication Standards
- Read the label of a product before using it
- Follow all safe work practices as instructed
- Wear required PPE and maintain it as instructed
- Report all exposures or near accidents to the supervisor
6. Annual Evaluation
The Pharmacy Manager will evaluate the Hazard Communication Plan every fiscal year to ensure:
- New employees have received proper training and have signed the Hazard Drug Risk Acknowledge Form.
- Employees have been trained in any new hazards and procedures.
- Every product in use is listed on the Inventory sheet and all SDS are available.
- Latest revision of Medication Dispensary written plan is implemented.
- The products and procedures evaluated in the Hazard assessment have not changed.
7. Reference to University of Illinois Hazard Communication Plan: https://www.drs.illinois.edu/site-documents/HazComWrittenPlan.pdf
Procedure (if applicable)
Definitions and abbreviations (if applicable)
HD : Hazardous Drug
SOP : Standard Operating Procedure
SDS : Safety Data Sheet
DHS : Department of
GHS : Globally Harmonized System of Classification and Labeling of Chemicals
PPE : Personal Protective Equipment
Exposure: Exposure or exposed means that an employee is subjected in the course of employment to a chemical that is a physical or health hazard and includes potential (e.g., accidental or potential) exposure. “Subjected" in terms of health hazards includes any route of entry (e.g., inhalation, ingestion, skin contact, or absorption).
Globally Harmonized System (GHS):The Globally Harmonized System of Classification and Labeling of Chemicals (GHS) is a system that defines and classifies the hazards of chemical products and communicates health and safety information on labels and material safety data sheets (called Safety Data Sheets, or SDSs, in GHS). These international standards became effective on June 1, 2015.
Hazardous Chemicals: OSHA defines a hazardous chemical as any chemical or mixture of chemicals classified as a physical hazard or a health hazard, a simple asphyxiant, combustible dust, pyrophoric gas, or a hazard not otherwise classified.
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.