Policy Manual sample

MDT Home Health Care Agency, Inc. 234 • Acute exposure episodes must be documented. The employee must be referred for professional examination. • All antineoplastic admixtures must be placed in a zip-lock bag labeled "CAUTION- CHEMOTHERAPY DRUG". This outer bag shall be delivered along with the proper drug information to the nurse responsible for administering the agent(s). A spill kit is dispensed with the chemotherapy drug. • All antineoplastic admixtures shall be labeled with actual dose, diluent, date and time of preparation, recommended rate of administration, preparer’s name, patient’s name and location. • Labeled bags must have injection port sealed before being dispensed from the pharmacy. • Before opening ampules, care shall be taken to insure that no liquid remains in the tip of the ampule. A sterile gauze sponge shall be wrapped around the neck of the ampule while opening. • Vials shall be vented with a filter needle to eliminate internal pressure or vacuum. • Syringes and IV sets with Luer-Lok fittings shall be used. • Filter needles (5 micron) shall be used to remove particulate matter and glass fragments from solutions provided in ampules prior to final admixture preparation. • Final drug measurement shall be performed prior to removing the needle from the stopper of the vial. • Special care must be taken in priming IV sets. The distal tip cover must be removed before priming. Priming shall be performed into a sterile gauze sponge, which then is disposed of appropriately. • Disposable gloves shall be worn for all procedures involving antineoplastic drugs. Double gloving is recommended. • Hands shall be washed with a suitable disinfecting solution thoroughly before and after gloving. • Care must be taken to avoid puncturing gloves and possible self-inoculation. • All potential contaminated garments or gloves shall not be worn outside the work area. DISPOSAL: All antineoplastic agents, wastes or materials shall be disposed of in special containers identified with a biohazard sign.