U-M Health to launch USP <800> Hazardous Drug Handling standards

December 1, 2022  //  FOUND IN: Strategy & Leadership

Key takeaways:

  • U-M Health will roll out USP (United States Pharmacopeia) <800> Hazardous Drug Handling standards on Feb. 28, 2023.
  • The new standards reclassify drugs based on the National Institute for Occupational Safety and Health (NIOSH) hazardous drug list.
  • Online training for all clinical staff will be available beginning Tues., Dec. 6, with additional hands-on training for nurses during January and February.

The U-M Health Hazardous Drug Oversight Committee (HDOC), with representatives from Pharmacy, Nursing and Safety Management Services, is preparing to launch USP (United States Pharmacopeia) <800> Hazardous Drug Handling standards on Feb. 28, 2023. USP <800> reclassifies drugs based on the National Institute for Occupational Safety and Health (NIOSH) hazardous drug list, and addresses health care worker safety while handling all hazardous drugs. 

“Currently, about two percent of the drugs administered at U-M Health fall within the hazardous drug category,” said Jamie Tharp, Pharm.D., BCSCP, compounding compliance manager in the Department of Pharmacy. “The reclassification of drugs based on NIOSH standards will increase that number to roughly three percent.”

Prior to the launch, most staff who work with patients or in patient care areas will be required to complete a 30-minute online universal training module, available in Cornerstone Learning starting Tuesday, Dec. 6. Two additional e-learnings will be required for employees who prepare or administer hazardous drugs during the normal course of their work, for a total of 60 minutes of online learning.

Hands-on demonstrations and checkoffs for donning and doffing personal protective equipment (PPE) and using closed system transfer devices and spill kits will be offered during the Nursing Blitz in January and February on the main medical campus. Mini blitz sessions are being planned for ambulatory care nurses at several offsite locations. Additional details will be shared at a later date.

What do the new standards mean for employees?

USP <800> implementation will create changes for staff who handle hazardous drugs or materials contaminated with hazardous drugs. Revised policies and procedures will apply to all staff with exposure to hazardous drugs including nurses, prescribers, pharmacy staff and support staff.

“Changes for staff include donning and doffing of PPE for drugs that will be reclassified by NIOSH standards,” said Katie Barwig, M.S., R.N.,nursing medication safety program manager in the Office of the Chief Nursing Officer.

“The reclassification means that hazardous drug precautions will be implemented outside of previous common locations like oncology and infusion centers,” she added.

Barwig said staff will be alerted to a drug’s hazardous classification in several ways, including banners on medication labels coming from Pharmacy, dispensing alerts at the Pyxis level and on the MAR PPR diagram.

Long history of safe drug handling

U-M Health has a long-standing program for safe handling of hazardous drugs, including the use of personal protective equipment (PPE) and closed system transfer devices for the safe preparation and administration of hazardous drugs.  

The HDOC has been working in collaboration with key stakeholders across the organization to align U-M Health’s hazardous drug handling standards with the classification standards established by NIOSH.

Additional information can be found in the UMH USP <800> Plan posted on the Hazardous Drug Resource page of the Dept. of Pharmacy website (offsite access requires VPN login). Questions can be addressed to Katie Barwig or Jamie Tharp.