Self-Assessment of Safe Handling Practices for Hazardous Drugs

Assess your organization’s readiness to handle hazardous drugs (HDs) according to recognized national standards, regulations, and best practices.

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About

The Self-Assessment of Safe Handling Practices for Hazardous Drugs was developed to assist health care organizations and individuals who handle hazardous drugs (HDs) understand and comply with regulatory standards and guidelines. Developed by leading experts in the field, The Self-Assessment addresses:

The newly released United States Pharmacopeial Convention (USP) Chapter <800> Hazardous Drugs-Handling in Healthcare Settings
The Joint Commission 2016 Comprehensive Accreditation Manual for Hospitals
American Society of Health-System Pharmacists (ASHP) Guidelines on Handling Hazardous Drugs
Oncology Nursing Society (ONS) Safe Handling of Hazardous Drugs, 2nd ed.
Centers for Medicare & Medicaid Services CMS Manual System. CMS Condition of Participation §482.11(a).
Occupational Safety and Health Administration (OSHA) HAZCOM 1994 Program Guidance
National Institute for Occupational Safety and Health (NIOSH) List of Antineoplastic and Other Hazardous Drugs in Healthcare Settings, Medical Surveillance for Healthcare Workers Exposed to Hazardous Drugs, NIOSH Alert: Preventing Occupational Exposures to Antineoplastic and Other Hazardous Drugs in Health Care Settings.

Use these nationally recognized standards and guidelines to assess your organization’s performance regarding the following HD areas:

The newly released United States Pharmacopeial Convention (USP) Chapter <800> Hazardous Drugs-Handling in Healthcare Settings
The Joint Commission 2016 Comprehensive Accreditation Manual for Hospitals
American Society of Health-System Pharmacists (ASHP) Guidelines on Handling Hazardous Drugs
Oncology Nursing Society (ONS) Safe Handling of Hazardous Drugs, 2nd ed.
Centers for Medicare & Medicaid Services CMS Manual System. CMS Condition of Participation §482.11(a).
Occupational Safety and Health Administration (OSHA) HAZCOM 1994 Program Guidance
National Institute for Occupational Safety and Health (NIOSH) List of Antineoplastic and Other Hazardous Drugs in Healthcare Settings, Medical Surveillance for Healthcare Workers Exposed to Hazardous Drugs, NIOSH Alert: Preventing Occupational Exposures to Antineoplastic and Other Hazardous Drugs in Health Care Settings.

Upon completing the self-assessment, you will be able to download a report that highlights the areas your organization needs to improve, as well as recommendations customized to your organization’s performance.

As your organization improves its handling of HDs, you can update your Self-Assessment and generate updated versions of your report.

Lead Author:

Jeannell Mansur, RPh, PharmD, FASHP, FSMSO
Practice Leader, Medication Safety, Joint Commission Resources

Expert Reviewers:

Patricia C. Kienle, RPh, MPA, FASHP
Director, Accreditation and Medication Safety, Cardinal Health Innovative Delivery Solutions

Eric S. Kastango, MBA, RPh, FASHP
President and CEO, Clinical IQ

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Additional Resources

Joint Commission Resources. Safe Handling Practices for Hazardous Drugs. Oakbrook, IL: The Joint Commission, 2016.
American Society of Health-System Pharmacists (ASHP). ASHP Guidelines on Handling Hazardous Drugs. www.ashp.org/DocLibrary/BestPractices/PrepGdlHazDrugs.aspx
Department of Health and Human Services (DHHS). Centers for Medicare & Medicaid Services. CMS Manual System. CMS Condition of Participation §482.11(a), Oct 17, 2008.
National Institute for Occupational Safety and Health (NIOSH). Medical Surveillance for Healthcare Workers Exposed to Hazardous Drugs, 2012 Nov. Cincinnati, OH: U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health DHHS (NIOSH) Publication No. 2013-103 (supersedes 2007-117). http://www.cdc.gov/niosh/docs/wp-solutions/2013-103/pdfs/2013-103.pdf
National Institute for Occupational Safety and Health (NIOSH). NIOSH Alert: Preventing Occupational Exposures to Antineoplastic and Other Hazardous Drugs in Health Care Settings. Sep 2004. Cincinnati, OH: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health, DHHS (NIOSH) Publication Number 2004−2165. Accessed 24 Nov 2015. www.cdc.gov/niosh/docs/2004-165/pdfs/2004-165.pdf
National Institute for Occupational Safety and Health (NIOSH). NIOSH List of Antineoplastic and Other Hazardous Drugs in Healthcare Settings, 2014 Sep. Cincinnati, OH: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Institute for Occupa-tional Safety and Health, DHHS (NIOSH) Publication No. 2014-138 (supersedes 2012-150). http://www.cdc.gov/niosh/docs/2014-138/
Occupational Safety and Health Administration (OSHA). HAZCOM 1994 Program Guidance. https://www.osha.gov/dsg/hazcom/solutions.html
Polovich M, editor. Safe Handling of Hazardous Drugs, 2nd ed. Pittsburgh: Oncology Nursing Society, 2011.
The Joint Commission. 2016 Comprehensive Accreditation Manual for Hospitals (CAMH). Oakbrook, IL: The Joint Commission, 2016.
United States Pharmacopeial Convention, Inc. <795> Pharmaceutical Compounding—Nonsterile Preparations. United States Pharmacopeia 37–National Formulary 32. Rockville, MD: US Pharmacopeial Convention, Inc., 2005.
United States Pharmacopeial Convention, Inc. <797> Pharmaceutical Compounding—Sterile Preparations. United States Pharmacopeia 31–National Formulary 26, 2nd Suppl. Rockville, MD: US Pharmacopeial Convention, Inc., 2008.
United States Pharmacopeial Convention, Inc. <800> Hazardous Drugs-Handling in Healthcare Settings. United States Pharmacopeia 39–National Formulary 34. Rockville, MD: US Pharmacopeial Convention, Inc., 2016.

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