AJN Article - May 2002: Hazardous Drugs: Handling medications can pose dangers to nurses

m Bookmark and Share

Health & Safety

American Journal of Nursing - May, 2002 - Volume 102, Issue 5

Hazardous Drugs
Handling medications can pose dangers to nurses.

By Karen A. Worthington, MS, RN, COHN-S

What are ‘hazardous drugs’ and what precautions should I take when administering them?

Most nurses are aware of the special handling precautions needed for the preparation, administration, and disposal of drugs used to fight cancer, known as cytotoxic drugs. Precautions are required because the drugs’ action is nonselective; that is, they üamage normal as well as abnormal cells. Furthermore, nonselective action isn’t limited to the intended patient—the Occupational Safety and Health Administration (OSHA) reports that when nurses and pharmacists were exposed to these drugs through dermal contact or inhalation, chromosomal changes, adverse reproductive outcomes, liver changes, and skin damage were observed. Whether any level of exposure to these drugs is safe for health care workers remains unknown, so OSHA and several professional groups including the Oncology Nursing Society and the American Society of Health-System Pharmacists recommend stringent handling precautions.

In addition to cytotoxic drugs, OSHA has identified other classes of hazardous drugs: antiviral agents, sex steroid hormones, immunosuppressive drugs, and anesthetic gases. Because these drugs also exhibit nonselective action, they pose health threats to workers and require special handling precautions. Although most drugs in these classes are administered intravenously, several are administered in aerosolized form; orally administered formulations of new drugs are becoming increasing popular. Health care workers can be exposed by skin contact with liquid or powder, inhalation of aerosolized drugs or vapors, and inadvertent ingestion. Health effects on workers are largely uninvestigated.


According to the American Society of Health-System Pharmacists, a drug should be considered hazardous if it:

  • causes cancer.
  • damages the developing fetus or impairs fertility.
  • causes chromosomal breakage.
  • produces serious organ toxicity at low doses.
There should be a plan in place at your health care facility for determining which drugs within the classes identified by OSHA are considered hazardous. Pharmacists, health care practitioners, and occupational health and safety specialists should be involved in developing policies and practices for safe handling. Under OSHA’s Hazard Communication Standard, health care workers are entitled to obtain from their employer the material safety data sheet for any hazardous agent to which they might be exposed, including a drug intended for a patient.


While most health care worker exposures to hazardous drugs occur during drug preparation and administration, safe handling practices must be employed from the time the drug enters the facility until its disposal (which includes the proper disposal of patients’ solid and liquid waste). Hazardous drugs should be prepared in a properly functioning Class II biological safety cabinet by staff who have been trained in safety and handling precautions. All personal protective equipment (PPE)—especially gloves and gowns—should offer proven barrier protection from the hazardous agents being used. Most often, this means a thick synthetic glove, often called a “chemo glove.” PPE manufacturers should be able to provide documentation of the testing performed against various chemical agents. Contaminated PPE and other equipment must be disposed of in properly labeled, leak-proof containers; staff members specially trained in such procedures should be assigned to clean up spills.

For liquid drugs, manufacturers are beginning to make safety systems to capture escaping liquid or airborne droplets released when iv ports and vials are accessed to prepare the drug. Just as safe devices can prevent needlestick exposures, safe drug administration systems may be one of the most effective ways to curb hazardous drug exposures.

Aerosolized hazardous drugs pose more complex problems. Ventilation systems must be tailored to exhaust hazardous gases safely, and proper respiratory protection must be provided to health care workers who care for patients receiving these drugs. No matter how therapeutic a drug may be for the patient, nurses have a right to be protected from unintended effects to themselves.

Karen A. Worthington is a senior occupational health and safety specialist at the ANA.