Hazardous Drugs Resources

About these resources

NIOSHTIC-2 is a database of occupational safety and health publications funded in whole or in part by NIOSH. These resources are meant to supplement those found on the NIOSHTIC-2 lists. See the NIOSHTIC-2 database search results for:

Additional resources regarding antineoplastic agents and research about Closed System Drug-Transfer Devices (CSTD) are also available.

Featured NIOSH publications

Managing Hazardous Drug Exposures: Information for Healthcare Settings
Describes risk management and scenarios that could occur when handling hazardous drugs.
NIOSH List of Antineoplastic and Other Hazardous Drugs in Healthcare Settings 2010 DHHS (NIOSH) Publication No. 2010-167 (September 2010)
NIOSH List of Antineoplastic and Other Hazardous Drugs in Healthcare Settings, 2014 DHHS (NIOSH) Publication No. 2014-138 (September 2014)
NIOSH List of Antineoplastic and Other Hazardous Drugs in Healthcare Settings, 2016 DHHS (NIOSH) Publication No. 2016-161 (September 2016)

Publications, guidelines, review articles and surveys

Publications

Cytotoxic Drugs and Related Waste: A Risk Management Guide for South Australian Health Services.

Gomez-Alvarez S, Porta-Oltra B, Hernandez-Griso M, Perez-Labana F and Climente-Marti M. Evaluacion de dos sistemas cerrados en el proceso de elaboracion de quimioterapia parenteral. Farm Hosp. 2016; 40:36-43.
Kienle PC. Prepare for Compliance: The Chapter <800> Answer Book. Pharm Purch Prod. 2017; 14(10):18-21.
Pérez-Minayo MF, Bazán EC, Segurado MH, Moya MAA, Torres PP and Martinez FJB. Use of closed systems in the hospital pharmacy. Farm Hosp. 2016; 40:102–17.

Power LA, Polovich M. Safe handling of hazardous drugs: reviewing standards for worker protection. Pharm Pract News 2016; Special Edition:23-36.

Rodier S, Saint-Lorant G, Guillot J-M, Palix A, Divanon F, Sichel F and Delépée R. Is hyperthermic intraperitoneal chemotherapy (HIPEC) safe for healthcare workers? Surg Oncol. 2017; 26:242–51.
Vyas N, Turner A, Clark JM and Sewell GJ. Evaluation of a closed-system cytotoxic transfer device in a pharmaceutical isolator. J Oncol Pharm Pract. 2016; 22(1):10-19.

Non-peer reviewed publications

The articles in this section, while not peer-reviewed, contain helpful “how-to” information for healthcare workers and others who work with antineoplastic and other hazardous drugs. Many provide reference material and links to additional background information.

Aguero D and Marge K. Developing a USP <800> compliance gap analysis. Pharm Purch Prod. 2017; 14(1):10–12.

Berdi F, Powell MF, Sanz C, Gonzalez R and Massoomi F. Assessing the efficiency of CSTDs for compounding. Pharm Purch Prod. 2015; 12:4–7.

Berrios V, Smith D and Reichard JS. USP <800> compliance in outpatient infusion clinics. Pharm Purch Prod. 2017; 14(12):2–4.

Buckley B. When outsourcing IV drug preparation makes sense. Pharm Pract News. 2016; 43(7):36–38.

Buckley B. 10 Tips for building a compliant cleanroom. Pharm Pract News. 2016; 43(12):8–10.

Buckley B. USP <800> tips can be applied to home infusion. Pharm Pract News. 2017; 44(2):11–12.

Buckley B. On the bumpy road to USP <800> compliance: a tale of 3 hospitals. Pharm Pract News. 2017; 44(4):1, 26–27.

Buckley B. Pharm-entrepreneurs seek a better surface wipe. Pharm Pract News. 2017; 44(8):37–38.

Buckley B. USP hits pause on <800>, but no time to rest. Pharm Pract News. 2017; 44(11):1, 10–11.

Douglass K. Compliant garbing practices for sterile compounding. Pharm Purch Prod. 2016; 13(7):22–24.

Douglass K. Best practices for garbing in HD sterile compounding. Pharm Purch Prod. 2016; 13(11):56–64.

Douglass K. Best practices for sterile compounding. Pharm Purch Prod. 2017; 14(1):6–9.

Douglas K, Richter A, Dorey M and Rizvi I. Refining PPE usage for HD compounding: Part 1. Pharm Purch Prod. 2017; 14(2):18–21.

Eberwein SM and Amerine LB. Comparison of USP <800> gap analysis tools. Pharm Purch Prod. 2017; 14(4):12–13.

Eisenberg S. Hazardous drug handling in light of USP <800>. Pharm Purch Prod. 2015; 12(2):18–19.

Houchard G, Lewis P, Hymel L, Prenosil S and Kisgen R. A comprehensive approach to USP <800> compliance. Pharm Purch Prod. 2017; 14(11):20–31.

Karpinski J. 2016 Updates to the NIOSH hazardous drug list. Pharm Purch Prod. 2017; 14(7):36–38.

Kastango E. 5 Reasons why USP compliance matters now. Pharm Pract News. 2017; 44(9):18.

Kienle P and Douglass K. Perform an assessment of risk to comply with USP <800>. Pharm Purch Prod. 2017; 14(3):26–31.

Kienle PC. Ensure USP <800> compliance beyond the pharmacy. Pharm Purch Prod. 2016; 13(9):2–4.

Kienle PC. Update on proposed USP Chapter <800>. Pharm Purch Prod. 2015; 12(2):2–4.

Krych RJ and Lupano C. USP-compliant outpatient center renovation. Part II. Pharm Purch Prod. 2017; 14(9):18–22.

Massoomi F and Eisenberg S. Pharmacy and nursing collaborate on CSTD training. Pharm Purch Prod. 2015; 12(5):12–16.

Massoomi F and Kvancz DA. USP <800> requirements for engineering control. Pharm Purch Prod. 2016; 13(12):16–22.

Massoomi F. The evolution of the CSTD. Pharm Purch Prod. 2015; 12(2):S1–S12.

Rinehart JR and Jorgenson JA. Considerations for handling monoclonal antibodies. Pharm Purch Prod. 2015; 12(5):S6–S10.

Rosenthal M. CSTD buyers need advocacy help. Pharm Pract News. 2016; April 4, online issue.

Rosenthal M. Establishing procedures for testing CSTDs (Parts 1 and 2). Pharm Pract News. 2017; 44(3):32–33.

Shaw G. CSTDs should be at center of health care worker safety. Pharm Pract News. 2017; 44(12):1, 18–19.

Shaw G. Do you know what's on the NIOSH HD list? Pharm Pract News. 2018; 45(1):16-17.

Wagner JT. Ensure safe use of CAIs and CACIs. Pharm Purch Prod. 2014; 11(12):12–14.

Guidelines

Beaver CC and Magnan MA. Minimizing staff exposure to antineoplastic agents during intravesical therapy. Clin J Oncol Nurs. 2015; 19:393-395.
Easty AC, Coakley N, Cheng A, Cividino M, Savage P, Tozer R and White RE. Safe handling of cytotoxics: guideline recommendations. Curr Oncol. 2015; 22:e27-e37.
Ferron G, Simon L, Guyon F, Glehen O, Goere D, Elias D, Pocard M, Gladieff L, Bereder JM, Brigand C, Classe JM, Guilloit JM, Quenet F, Abboud K, Arvieux C, Bibeau F, De Chaisemartin C, Delroeux D, Durand-Fontanier S, Goasguen N, Gouthi L, Heyd B, Kianmanesh R, Leblanc E, Loi V, Lorimier G, Marchal F, Mariani P, Mariette C, Meeus P, Msika S, Ortega-Deballon P, Paineau J, Pezet D, Piessen G, Pirro N, Pomel C, Porcheron J, Pourcher G, Rat P, Regimbeau JM, Sabbagh C, Thibaudeau E, Torrent JJ, Tougeron D, Tuech JJ, Zinzindohoue F, Lundberg P, Herin F and Villeneuve L. Professional risks when carrying out cytoreductive surgery for peritoneal malignancy with hyperthermic intraperitoneal chemotherapy (HIPEC): a French multicentric survey. Eur J Surg Oncol. 2015; 41:1361-1367.
Garrigue P, Montana M, Ventre C, Gauthier-Villano L, Pisano P and Pourroy B. Safe cytotoxic drug preparation using closed-system transfer device: technical and practical evaluation of a new device (Vialshield/Texium) comparatively to a reference one (Phaseal). Int J Pharm Compounding. 2016; 20:148-154.
Guillemette A, Langlois H, Voisine M, Merger D, Therrien R, Mercier G, Lebel D and Bussieres JF. Impact and appreciation of two methods aiming at reducing hazardous drug environmental contamination: The centralization of the priming of IV tubing in the pharmacy and use of a closed-system transfer device. J Oncol Pharm Practice. 2014; 20:426-432.
Health and Safety Executive. Safe handling of cytotoxic drugs in the workplace.

National Institutes of Health Publication. Recommendations for the Safe Handling of Cytotoxic Drugs. US DHHS PHS, NIH Pub No. 92-2621.

Rudnitzki T and McMahon D. Oral agents for cancer: safety challenges and recommendations. Clin J Oncol Nurs. 2015; 19 (Suppl):41-46.

Süle A. Safety assessment and revision of a central cytostatic unit base on ESOP guidelines. Eur J Oncol Pharm. 2014; 8:19-23.

Tomkins J. Ensuring health care worker safety when handling hazardous drugs: the joint position statement from the Oncology Nursing Society, the American Society of Clinical Oncology and the Hematology/Oncology Pharmacy Association. Eur J Oncol Pharm. 2015; 11:278-279.

Review articles

Several authors have published articles reviewing the topic of occupational exposure. These articles provide a good starting place for individuals not familiar with this area to learn more of what some of the issues are and what type of studies have been performed in this area.

Alehashem M and Baniasadi S. Important exposure controls for protection against antineoplastic agents: highlights for oncology health care workers. Work 2018; 59:165-172.
Bach PB, Conti RM, Muller RJ, Schnorr GC and Saltz LB. Overspending driven by oversized single dose vials of cancer drugs. BMJ. 2016; 352:i788.
Chen H-C, Lu Z-YJ and Lee S-H. Nurses’ experiences in safe handling of chemotherapeutic agents: the Taiwan case. Cancer Nursing. 2016; 39:e29–38.
Eisenberg S. A call to action for hazardous drug safety: Where we have been and where we are going. Clin J Onc Nurs. 2016; 20: A1-A8.
Eisenberg S. Hazardous drugs and USP <800>: implications for nurses. Clin J Oncol Nurs. 2017; 21:179–187.
Meade E. Avoiding accidental exposure to intravenous cytotoxic drugs. Br J Nurs. 2014; 23:S34, S36-39.
Sussman RG, Schatz AR, Kimmel TA, Ader A, Naumann BD and Weideman PA. Identifying and assessing highly hazardous drugs within quality risk management programs. Regul Toxicol Pharmacol. 2016; 79:S11–18.
Toolaram AP, Kummerer K and Schneider M. Environmental risk assessment of anti-cancer drugs and their transformation products: a focus on their genotoxicity characterization-state of knowledge and short comings. Mutat Res Rev Mutat Res. 2014; 760:18-35.
Walton AML, Eisenberg S and Friese CR. Hazardous drugs: legislative and regulatory efforts to improve safe handling. Clin J Oncol Nurs. 2017; 21:254–256.

Surveys

A number of surveys have examined work practice standards and compliance with guidelines for the proper handling of hazardous drugs such as antineoplastic agents.

Al-Azzam SI, Awawdeh BT, Alzoubi KH, Khader YS and Alkafajei AM. Compliance with safer handling guidelines of antineoplastic drugs in Jordanian hospitals. J Oncol Pharm Pract. 2015; 21 (1):3-9.
Alexander M, King J, Lingaratnam S, Byrne J, MacMillan K, Mollo A, Kirsa S and Green M. A survey of manufacturing and handling practices for monoclonal antibodies by pharmacy, nursing and medical personnel. J Oncol Pharm Pract. 2016; 22(2):219-227.
Dekyndt B, Decaudin B, Lannoy D and Odou P. Economic assessment of aseptic compounding rooms in hospital pharmacies in five European countries. J Oncol Pharm Pract. 2015; 21:102-110.
Hon CY, Barzan C and Astrakianakis G. Identification of knowledge gaps regarding healthcare workers’ exposure to antineoplastic drugs: review of literature, North America versus Europe. Saf Health Work. 2014; 5:169-174.
Hon CY and Abusitta D. Causes of health care workers’ exposure to antineoplastic drugs: an exploratory study. Can J Hosp Pharm. 2016; 69:216-223.
Jeong KW, Lee BY, Kwon MS and Jang JH. Safety management status among nurses handling anticancer drugs: nurse awareness and performance following safety regulations. Asian Pac J Cancer Prev. 2015; 16:3203-3211.
Kieffer C, Verhaeghe P, Lagrassa S, Gregoire R, Moussaoui Z, Casteras-Ducros C, Clark JE, Vanelle P and Rathelot P. Preventing the contamination of hospital personnel by cytotoxic agents: evaluation and training of the para-professional healthcare workers in oncology units. Eur J Cancer Care. 2015; 24:404-410.
Pedersen CA, Schneider PJ and Scheckelhoff DJ. ASHP national survey of pharmacy practice in hospital settings: dispensing and administration – 2014. 2015; 72:1119-1137.
Roop JC and Wu HS. Current practice patterns for oral chemotherapy: results of a national survey. Oncol Nurs Forum. 2014; 41:185-194.
Shahrasbi AA, Afshar M, Shokraneh F, Monji F, Noroozi M, Ebrahimi-Khojin M, Madani SF, Ahadi-Barzoki M and Rajabi M. Risks to health professionals from hazardous drugs in Iran: a pilot study of understanding of healthcare team to occupational exposure to cytotoxics. EXCLI Journal (ISSN 1611-2156). 2014; 13:491-501.

Effects of occupational exposure

Only a limited number of studies have examined health effects related to occupational exposure. However, for hazardous drugs such as antineoplastic agents, both acute and chronic effects have been well-documented in patients receiving treatment with these agents.

Gilani S and Giridharan S. Is it safe for pregnant health-care professionals to handle cytotoxic drugs? A review of the literature and recommendations. Ecancermedicalscience. 2014; 8:418.
Grases F, Costa-Bauzά A, Bonarriba CR, Pieras EC, Fernάndez RA and Rodrίguez A. On the origin of calcium monohydrate papillary renal stones. Urolithiasis. 2015; 43 (Supp 1):S33-S39.
King J, Alexander M, Byrne J, MacMillan K, Mollo A, Kirsa S and Green M. A review of the evidence for occupational exposure risks to novel anticancer agents – A focus on monoclonal antibodies. J Oncol Pharm Pract. 2016;22(2):121-134.
Shirangi A, Bower C, Holman CDJ, Preen DB and Bruce N. A study of handling cytotoxic drugs and risk of birth defects in offspring of female veterinarians. Int J Environ Res Public Health. 2014; 11:6216-6230.
Whitaker P. Occupational allergy to pharmaceutical products. Curr Opin Allergy Clin lmmunol 2016; 16:101-106.
Zhang X, Zheng Q, Lv Y, An M, Zhang Y, Wei Y and Feng W. Evaluation of adverse health risks associated with antineoplastic drug exposure in nurses at two Chinese hospitals: the effects of implementing a pharmacy intravenous admixture service. Am J Ind Med. 2016; 59:264–273.

Occupational monitoring: biological studies

Several biological endpoints have been employed to monitor healthcare workers’ exposure to hazardous drugs such as antineoplastic agents. Most of these endpoints measure various types of genotoxic damage.

Deschamps F, Marinutti-Liberge and Lamiable D. Biological monitoring of occupational exposure to cytostatic drugs with platinum . Cancer Detect Prev Online.

Gianfredi V, Salvatori T, Nucci D, Villarini M and Moretti M. Rischio genotossico da manipolazione di farmad chemioterapid antiblastid negli operatori sanitari professionalmente esposti: revisione sistematica della letteratura e meta-analisi. Recenti Prog Med 2017; 108:511-520. (Italian with English abstract)
Hon CY, Teschke K, Shen H, Demers PA and Venners S. Antineoplastic drug contamination in the urine of Canadian healthcare workers. Int Arch Occup Environ Health. 2015; 88:933-941
Ladeira C, Viegas S, Padua M, Gomes M, Carolino E, Gomes MC and Brito M. Assessment of genotoxic effects in nurses handling cytostatic drugs. J Toxicol Environ Health. 2014; 77:879-887.
McDiarmid MA, Rogers B and Oliver MS. Chromosomal effects of non-alkylating drug exposure in oncology personnel. Environ Mol Mutagen. 2014; 55:369-374.
Moretti M, Grollino MG, Pavanello S, Bonfiglioli R, Villarini M, Appolloni M, Carrieri M, Savatini L, Dominici L, Stronati L, Mastrangelo G, Barbieri A, Fatigoni C, Bartolucci GB, Ceretti E, Mussi F and Monarca S. Micronuclei and chromosome aberrations in subjects occupationally exposed to antineoplastic drugs: a multicentric approach. Int Arch Occup Environ Health. 2015; 88:683-695.
Sakhvidi MJZ, Hajaghazadeh M, Mostaghaci M, Mehrparvar AH, Sakhvidi FZ and Naghshineh E. Applicability of the comet assay in evaluation of DNA damage in healthcare providers’ working with antineoplastic drugs: a systematic review and meta-analysis. Int J Occup Environ Health. 2016; 22:52-67.

Environmental sampling

Environmental sampling is a relatively new approach used to determine the level of workplace contamination by antineoplastic agents. The procedure has been used extensively in other situations, especially for monitoring contamination by radioactive materials. Typically, work surfaces are sampled with a moistened wipe and the material is extracted and analyzed for specific antineoplastic agents. Currently, it is possible to identify and quantitate six to eight agents with this technique.

Ametsbichler P, Böhlandt A, Nowak D and Schierl R. Occupational exposure to cisplatin/oxaliplatin during Pressurized Intraperitoneal Aerosol Chemotherapy (PIPAC)? Eur J Surg Oncol 2018; 44:1793-1799.
Bourget P, Amin A, Vidal F, Merlette C, Troude P and Baillet-Guffroy A. The contribution of Raman spectroscopy to the analytical quality control of cytotoxic drugs in a hospital environment: eliminating the exposure risks for staff members and their work environment. Int J Pharm. 2014; 470:70-76.
Breukels O, van der Gronde T, Simons-Sanders K and Crul M. Antineoplastic drug contamination on the outside of prepared infusion bags. IJPC Intern J Pharmaceutical Compounding 2018; 22:345-349.
Federica DB, Santoro V, Scarpino V, Martano C, Aigotti R, Chiappa A, Davoli E and Medana C. Antineoplastic drugs determination by HPLC-HRMSn to monitor occupational exposure. Drug Test Anal. 2016; 8:730-737.
Fent K and Mueller C. Pharmaceutical dust exposure at pharmacies using automatic dispensing machines: a preliminary study. J Occup Environ Hyg. 2014 (Epub ahead of printing) DOI: 10.1080/15459624.2014.918983.
Fleury-Souverain S, Mattiuzzo M, Mehl F, Nussbaumer S, Bouchoud L, Falaschi L, Gex-Fabry M, Rudaz S, Sadeghipour F and Bonnabry P. Evaluation of chemical contamination of surfaces during the preparation of chemotherapies in 24 hospital pharmacies. Eur J Hosp Pharm. 2015; 22:333-341.
Fleury-Souverain S, Nussbaumer S, Mattiuzzo M, Bonnabry P. Determination of the external contamination and cross-contamination by cytotoxic drugs on the surfaces of vials available on the Swiss market. J Oncol Pharm Practice. 2014; 20:100-111.
Gómez-Canela C, Ventura F, Caixach J and Lacorte S. Occurrence of cytostatic compounds in hospital effluents and wastewaters, determined by liquid chromatography coupled to high-resolution mass spectrometry. Anal Bioanal Chem. 2014; 406:3801–3814.
Hon CY, Teschke K, Demers PA and Venners S. Antineoplastic drug contamination on the hands of employees working throughout the hospital medication system. Ann Occup Hyg. 2014; 58:761-770.
Jeonimo M, Colombo M, Astrakianakis G and Hon CY. A surface wipe sampling and LC-MS/MS method for the simultaneous detection of six antineoplastic drugs commonly handled by healthcare workers. Anal Bioanal Chem. 2015 (Epub ahead of print). DOI: 10.1007/s00216-015-8868-y.
Le LMM, Reitter D, He S, Bonle FT, Launois A, Martinez D, Prognon P and Caudron E. Safety analysis of occupational exposure of healthcare workers to residual contaminations of cytotoxic drugs using FMECA security approach. Sci Total Environ. 599-600 (2017) 1939-1944.
Merger D, Tanguay C, Langlois E, Lefebvre M and Bussieres JF. Multicenter study of environmental contamination with antineoplastic drugs in 33 Canadian hospitals. Int Arch Occup Environ Health. 2014; 87:307-313.
Müller-Ramírez C, Squibb K and McDiarmid M. Measuring extent of surface contamination produced by the handling of antineoplastic drugs in low-to-middle-income country oncology health care settings. Arch Occup Environ Health. 2017; 72:289-298.
Odraska P, Dolezalova L, Kuta J, Oravec M, Piler P, Synek S and Blaha L. Association of surface contamination by antineoplastic drugs with different working conditions in hospital pharmacies. Arch Environ Occup Health. 2014; 69:148-158.
Panahi D, Azari M, Akbari ME, Zendehdel R, Mirzaei HR, Hatami H and Mehrabi Y. Development of a new method for sampling and monitoring oncology staff exposed to cyclophosphamide drug. Environ Monit Assess. 2016; 188:238-243.
Power LA, Sessink PJM, Gesy K and Charbonneau F. Hazardous drug residue on exterior vial surfaces: evaluation of a commercial manufacturing process. Hosp Pharm. 2014; 49:355-362.
Villa AF, El Balkhi S, Aboura R, Sageot H, Hasni-Pichard H, Pocard M, Elias D, Joly N, Payen D, Blot F, Poupon J and Garnier R. Evaluation of oxaliplatin exposures of healthcare workers during heated intraperitoneal perioperative chemotherapy (HIPEC). Ind Health. 2015; 53:28-37.

Vazquez R, Boubet K, Guerrault-Moro MN and Crauste-Manciet S. Impact of handling errors for chemical cross-contamination risk for the preparation of parenteral cytotoxic drugs. Pharm Technol Hosp Pharm. 2016;1:115-122.

Viegas S, Padua M, Veiga AC, Carolino E and Gomes M. Antineoplastic drugs contamination of workplace surfaces in two Portuguese hospitals. Environ Monit Assess. 2014; 186:7807-7818.

Robotics

Masini C, Nanni O, Antaridi S, Gallegati D, Marri M, Paolucci D, Minguzzi M and Altini M. Automated preparation of chemotherapy: quality improvement and economic sustainability. Am J Health-Sys Pharm. 2014; 71:579-585.
Nurgat Z, Faris D, Mominah M, Vibar A, AL-Jazairi A, Ewing S, Ashour M, Qaisi SK, Balhareth S and AL-Jedai A. A three-year study of a first-generation chemotherapy-compounding robot. Am J Health-Syst Pharm. 2015; 72:1036-1045.
Palma E and Bufarini C. Robotized compounding of oncology drugs in a hospital pharmacy. Int J Pharm Compd. 2014; 18:358-364.
Schierl R, Masini C, Groeneveld S, Fischer E, Bohlandt A, Rosini V and Paolucci D. Environmental contamination by cyclophosphamide preparation: comparison of conventional manual production in biological safety cabinet and robot-assisted production by APOTECAchemo. J Oncol Pharm Practice. 2016; 22:37-45.
Sessink PJM, Leclercq GM, Wouters DM, Halbardier L, Hammad C and Kassoul N. Environmental contamination, product contamination and workers exposure using a robotic system for antineoplastic drug preparation. J Oncol Pharm Practice. 2015; 21
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Published: May 15, 2024
Updated: March 3, 2026

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Reviewed: March 3, 2026

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