Reduce exposure to the hazards

To minimize the potential for dosing error, vial sizes closest to the actual dose should be selected. Only one drug should be in the CDSC at any one time or one drug per operator in a 2 person CDSC. Opened, used vials should not be left in the CDSC for later use. Parenteral preparations, in this aspect, safe work procedures should be documented and address the need to avoid using cytotoxic drugs supplied in glass ampoules. if glass ampoules must be used, open with an ampoule breaker or a low-linting swab, contain excess drug solutions and air when priming, or use techniques that avoid the generation of pressure differentials.

For Non-parenteral preparations, If the preparation of creams, mixtures or ophthalmic preparations is required, they should be prepared under the same conditions as parenteral cytotoxic drugs. Additional safe work procedures should include using purpose-dedicated equipment, making mixtures by dispersing tablets in water preferably inside a cytotoxic drug safety cabinet, not crushing tablets in an open mortar, not counting tablets or capsules by machine. Non-parenteral preparations, including oral tablets and capsules these must be handled in a manner so as to avoid or minimize risk contact and liberation of powdered drug. They must also be handled in a manner that avoids chemical cross-contamination with other drugs Equipment used to prepare cytotoxic drugs and air-handling facilities should be maintained under a planned maintenance schedule.

Defective equipment must not be used. Cytotoxic drug safety cabinet secondary and tertiary barriers should be assessed and certified by a suitable qualified person.

Pressure differentials between rooms- before beginning work, usually daily. If access to plant is required for the purpose of maintenance, cleaning or repair, the plant must be stopped and one or more of the following measures so as to control risks to health and safety, for example, lockout or isolation devices, danger tags, permit-to-work systems, decontamination prior to maintenance this is essential. Equipment commissioning, decommissioning, maintenance, testing and inspection must be carried out by a competent person, in accordance with manufactures recommendations. Equipment maintenance schedule must include inspection of cytotoxic drug safety cabinets, isolators and suitable filters as required by the government, inspection at regular intervals, and at least every 12 months, inspection after relocation, and after mechanical or electrical maintenance.

The test records and a summary of results in a place accessible to all workers. identification of faulty cabinets, for example, attach a lock-out tag and do not use until repairs and clearance for use is authorised by a competent person, repair of faulty cabinet faults, and recertification, commissioning prior to use, or routine performing and recording of microbial and air-particle testing Daily and weekly routines should be established and all equipment used in the cleaning should be dedicated for the purpose. Cleaning should include bench tops and surfaces, grilles, filters, cabinets, floors, walls and ceilings. Written safe work procedures, including PPE requirements, should be developed for the cleaning of cytotoxic drug facilities and equipment and a cleaning log maintained.

General cleaning staff including contractors, who may be involved in cleaning cytotoxic drug preparation suites and associated equipment, must be informed of the potential hazards associated with cytotoxic drugs and be trained in safe cleaning procedures for low risk workers. They should also be educated on the extent of surface contamination involving cytotoxic drugs in areas both inside the preparation area and outside of it, and their important role in primarily the removal of this contamination or in the decontamination of these surfaces. Appropriate warning labels should be on cytotoxic drug containers, including syringes and IV bags, for example, put a label with ‘Caution — Cytotoxic Drug’. Appropriate advisory labels as per latest edition of your local government.

Containers that carry cytotoxic drugs should identify the contents as cytotoxic drugs. Cytotoxic drugs prepared for intrathecal use must be labelled on both the syringe and outer container with the warning, for example, ‘For Intrathecal Use Only’. Intrathecal drugs must be clearly identifiable and segregated from other preparations. Vinca alkaloids should be labelled ‘For intravenous use only — fatal if given by other routes’ and be supplied in a mini-bag around 50 cc or 100 cc, not in a syringe. Oral medications should be labelled ‘do not cut or crush’. Topical cytotoxic medication, for example, fluorouracil cream should be labelled ‘wear disposable gloves and use spatula to apply’. Cytotoxic drugs that are vesicants should have an extravasation warning label.

If we use Level 3 Risk Control Measure, which is Personal Protective Equipment, this is the lowest control priority in the hierarchy of control measures. Higher levels of control options should be fully investigated before PPE is selected. It should be appropriate for the individual and the task. It should be readily available. The PPE should be clean and functional and also correctly used when fitted