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

Disclaimer

Joint Commission Resources’ (JCR) production of this tool, as sponsored by BD, is on a non-exclusive basis and is not an endorsement of that company or its products, or a statement that its expertise or products are superior to those of other comparable companies. JCR and The Joint Commission, as a matter of policy, do not endorse products.

JCR products support, but are separate from, the accreditation activities of The Joint Commission. Users of JCR products receive no special consideration or treatment in, or confidential information about, the accreditation process.

The inclusion of an organization name, product, or service in a JCR product should not be construed as an endorsement of such organization product, or service, nor is failure to include an organization name, product, or service to be construed as disapproval.

This product is designed to provide accurate and authoritative information in regard to the subject matter covered. Every attempt has been made to ensure accuracy at the time of publication; however, please note that laws, regulations, and standards are subject to change. Please also note that some of the examples in this product are specific to the laws and regulations of the locality of the facility. The information and examples in this product are provided with the understanding that neither the publisher nor its sponsor is engaged in providing medical, legal, or other professional advice. If any such assistance is desired, the services of a competent professional should be sought.

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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.

Contact

If you have any questions, please send an email to SafeHandling@bd.com

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