Receiving and Unpacking of Hazardous Drugs
VTH Policy: PharmH659
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 appropriate processes for receiving of hazardous drugs from suppliers, including unpacking and processing prior to storage. This is applicable to all personnel involved in the receiving and unpacking of hazardous drugs.
Personnel must don appropriate PPE for the receiving and unpacking of hazardous drugs. Receiving and unpacking must occur in specified areas as denoted in “Designation of Hazardous Areas.”
Hazardous drugs will be received and handled appropriately with necessary PPE and unpacked in designated area(s).
- The designated entrance will have a clearly visible sign to the hazardous drug handling area. This area must be away from any area that is designated for food / drink.
- Access to the designated receiving area will be restricted to authorized personnel.
- A spill kit must be accessible in the receiving area.
Procedure (if applicable)
- Drug containers, individual dosage units, outer containers, work surfaces or floors may have hazardous drug residues present. Due to this nature, single chemo-rated gloves are required when opening the shipping container tote, and additional PPE may be required. If leaks/spills are possible, wear protective chemotherapy gown and respiratory protection.
- First, visually examine the shipping container for any signs of damage or breakage. This may include visible stains from leakage or sounds of broken glass.
- If shipping container appears damaged, do not open and seal the container. Contact the supplier. If unopened container is to be returned to the supplier, enclose the package in an impervious container and label the outer container “Hazardous”. If supplier declines the return, dispose of as hazardous waste.
- If shipping container is damaged and must be opened, seal the container in plastic/ or impervious container and transport it to a C-PEC and place on a plastic-backed preparation mat. Open the package and remove undamaged items. Wipe the outside of undamaged items with a disposable wipe and appropriate solution for decontamination prior to adding to stock. Enclose the damaged item(s) in an impervious container and label the outer container “Hazardous”. If supplier declines return, dispose of as HD waste. Deactivate, decontaminate and clean the C-PEC. Dispose the mat and cleaning disposables as hazardous waste.
- Damaged packages or shipping cartons must be considered as spills that must be reported to the designated person and managed according to “Hazardous Drug Spills.” Segregate hazardous drugs waiting to be returned to the supplier in a designated negative pressure area. Additionally, clean-up must comply with established SOPs/Policies.
- Antineoplastic HD and HD APIs ( must be unpacked (such as removal from external shipping containers) in an area that is neutral/normal or negative pressure relative to the surrounding areas. HDs must not be unpacked in sterile compounding areas or in positive pressure areas.
- Hazardous drugs must be delivered to the hazardous drug storage area immediately after unpacking.
Definitions (if applicable)
NIOSH : National Institute of Occupational Health and Safety
HD : Hazardous Drug
PPE : Personal Protective Equipment
SOP : Standard Operating Procedure
C-PEC : Primary Engineering Control
- Hood located within the cleanroom
API : Active Pharmaceutical Ingredient
- Any substance or mixture of substances intended to be used in the compounding of a drug preparation, thereby becoming the active ingredient in that preparation and furnishing pharmacological activity or other direct effect in the diagnosis, cure, mitigation, treatment, or prevention of disease in humans and animals or affecting the structure and function of the body.
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.