Storage of Hazardous Drugs

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.

Policy

The intent of this policy is to define the process for storing hazardous drugs in the designated area. Storage practices must meet applicable safety precautions. This is applicable to all personnel that may handle and be involved in the storage of hazardous drugs.

Personnel must don appropriate PPE while handling and storing hazardous drugs in the designated area.

Guidelines

Hazardous drugs must be received and handled with necessary PPE, unpacked in the designated area, and stored according to hospital and USP requirements.

Procedure (if applicable)

1. HDs must be stored in a manner that prevents spillage or breakage if the container falls. Hazardous drugs cannot be stored on the floor and must be stored with safety precautions that consider natural disasters that may occur in the area (e.g., tornados).
   1. In the VTH Dispensary HD cleanroom, HDs are stored in bins to contain the drugs, with proper labeling (drug name, storage conditions). Shelving in the negative pressure cleanroom has lips to hold the bins in place. Additional items in the cleanroom include PPE, cleaning supplies, spill kits, and CSTDs.
      
      
2. The designated area for HDs must have a clearly visible sign to the entrance of area. This area must be away from where food/drink are consumed. Access to this area must be restricted to authorized personnel.
   
   
3. Antineoplastics that require manipulation and HD APIs must be stored separately from non-hazardous drugs to prevent contamination and personnel exposure. These must be stored in an externally ventilated, negative pressure room with at least 12 ACPH.
   
   
4. Refrigerated antineoplastics must be stored in a dedicated refrigerator in an externally ventilated, negative-pressure area with at least 12 ACPH.
   
   
5. Non-antineoplastic, reproductive-risk-only HDs, and final dosage forms of antineoplastic HDs can be stored with other inventory, given that they are denoted as being HDs.
   
   
6. Appropriate PPE required for the handling and storage of HDs :
   1. A single pair of chemotherapy gloves
      
      
7. If leaks or spills are possible, appropriate PPE includes:
   1. Disposable chemotherapy gown
   2. Respiratory protection (e.g., N95 mask)
      
      

Definitions (if applicable)

HD : Hazardous Drug

PPE : Personal Protective Equipment

CSTD : Closed System Transfer Device

ACHP : Air Changes Per Hour

API : Active Pharmaceutical Ingredient

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.