U-M Health launch of USP <800> Hazardous Drug Handling Standards postponed to April

Key takeaways:

• The U-M Health rollout of USP (United States Pharmacopeia) <800> Hazardous Drug Handling standards scheduled for late February will now take place on April 4.
• 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 began in December 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 postponing the launch of USP (United States Pharmacopeia) <800> Hazardous Drug Handling standards until April 4. 

Delaying the rollout, which was supposed to take place in late February, will provide additional time to ensure that all unit periodic automatic replenishment (PAR) locations are adequately stocked and afford staff and area trainers additional time to complete eLearning and in-person learning assignments.

What is USP <800>?

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, assistant director of compounding compliance 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 are required to complete a 30-minute online universal training module (UMHS-62070), available in Cornerstone. Two additional e-learnings (UMHS-62072, UMHS-62073) are 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 were offered during the Nursing Blitz in January and February. Mini blitz sessions are also being offered for ambulatory care nurses at several offsite locations.

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 Department of Pharmacy website (remote access requires VPN login). Questions can be addressed to Katie Barwig or Jamie Tharp.