Health and Safety Practices Survey of Healthcare Workers

Antineoplastic Drug Administration – Effects of Organizational Safety Practices and Perceived Safety Climate on Use of Exposure Controls and Adverse Events

Here you will learn what we found regarding factors that may affect use of personal protective equipment (PPE) and engineering controls and the likelihood of adverse events during administration of liquid antineoplastic drugs. We also provide links to other studies that have examined factors for safe handling of antineoplastic drugs.


Antineoplastic drugs, also known as chemotherapy, cytotoxic and oncology drugs, are used to treat cancer, as well as arthritis, multiple sclerosis, and other non-cancer medical conditions. Most antineoplastic drugs are classified by NIOSH as hazardous drugs.1 About 8 million U.S. healthcare workers are potentially exposed to hazardous drugs.2

Healthcare workers exposed to chemotherapy drugs have increased risk3 of

  • Leukemia
  • Other cancers
  • Adverse reproductive outcomes
  • Chromosomal damage

Guidelines on the safe handling of antineoplastic drugs have been available for many years.3-6 However, the use of exposure controls (e.g., PPE, engineering controls) is lacking and varies, which can put healthcare workers at risk of exposure to antineoplastic drugs.7-13

This study provided an opportunity to (1) examine how likely nurses use personal protective equipment (PPE) and engineering controls, and (2) experience adverse events (spill/leak or skin contact) when administering liquid antineoplastic drugs to patients. We were particularly interested in examining the role of organizational safety practices and safety climate perceptions on these two outcomes.

Survey responses were analyzed from 1,814 oncology nurses, infusion nurses and hematology/oncology nurses who administered liquid antineoplastic drugs in the seven days prior to the survey and worked for a hospital or an ambulatory setting.

Among the nurses who administered liquid antineoplastic drugs, we found

  • Approximately 14% of nurses reported a spill or skin contact during the week prior to the survey.
  • Use of engineering controls and PPE was better:
    • in non-profit and government compared to for-profit settings
    • when workers were more familiar with safe handling guidelines
    • when specific safe handling procedures were present
    • when perceived management commitment to safety was higher
  • The more familiar nurses were with safe handling guidelines and had received training in safe handling practices, the more likely they were to use PPE consistently
  • Adverse events were more likely to occur when:
    • the number of antineoplastic drug treatments were higher
    • when treatments were administered on more days of the week.
  • Adverse events were less likely to occur when:
    • use of engineering controls and PPE was greater
    • precautionary measures were in place
    • there was greater management commitment to safety and perceived risk

Particularly where management had a higher commitment to safety, we found safety climate perceptions (1) contribute to the use of engineering controls and PPE, and (2) reduce spills/leaks and skin contact to liquid antineoplastic drugs beyond organizational practices specific to safe handling of such drugs.

What can be done to reduce exposure to antineoplastic drugs

  • Commitment from both healthcare management and workers is essential to minimize exposure to antineoplastic drugs, many of which are recognized carcinogens with no safe level of exposure.
  • Employers should implement a comprehensive health and safety program that uses available hazard controls and effectively communicates and demonstrates the importance of safe handling practices for antineoplastic drugs. Such actions can contribute to a positive safety climate.


1 National Institute for Occupational Safety and Health (NIOSH). NIOSH list of antineoplastic and other hazardous drugs in health care settings 2016

2 NIOSH Workplace solutions: Personal protective equipment for health care workers who work with hazardous drugspdf icon

3 NIOSH Alert on preventing occupational exposures to antineoplastic and other hazardous drugspdf icon

4 ASHP (American Society of Health-System Pharmacists) guidelines on handling hazardous drugsexternal icon

5 OSHA Controlling occupational exposure to hazardous drugspdf icon

6 Oncology Nursing Society (ONS) Chemotherapy and biotherapy guidelines and recommendations for practiceexternal icon

7 Boiano JM, Steege AL, Sweeney MH. [2014] Adherence to safe handling guidelines by health care workers who administer antineoplastic drugs. J Occup Environ Hyg 11(11):728–740.

8 Hon CY, Teschke K, Shen H. [2015] Healthcare workers’ knowledge, perceptions and behaviors regarding antineoplastic drugs: Survey from British Columbia, Canada. J Occup Environ Hyg 12(10):669-677.

9 Friese CR, Himes-Ferris, LMN, Frasier MC, McCullagh MC, Griggs JJ. [2012]Structures and processes of care in ambulatory oncology settings and nurse-reported exposure to chemotherapy. BMJ Qual Safety 21:753-759.

10 Fuller TP, Bain EI, Sperrazza K. [2007] A survey of the status of hazardous drug awareness and control in a sample Massachusetts nursing population. J Occup Environ Hyg 4:D113-119.

11 Martin S, Larson E. [2003] Chemotherapy-handling practices of outpatient and office based oncology nurses. Oncol Nurs Forum 30(4):575-581.

12 Polovich M, Martin S. [2011] Nurses’ use of hazardous drug-handling precautions and awareness of national safety guidelines. Oncol Nurs Forum 38:718-26.

13 Silver SR, Steege AL, Boiano JM. [2016] Predictors of adherence to safe handling practices for antineoplastic drugs: A survey of hospital nurses. J Occup Environ Hyg 13(16):203-212.

Learn more about factors that may affect adherence to safe handling guidelines for antineoplastic drugs

Ben-Ami S, Shaham J, Rabin S, Melzer A, Ribak J. [2001] The influence of nurses’ knowledge, attitudes, and health beliefs on their safe behavior with cytotoxic drugs in Israel. Cancer Nurs 24:192-200.

Friese CR, McArdle C, Zhao T, Sun D, Spasojevic I, Polovich M and McCullagh MC. [2015] Antineoplastic drug exposure in an ambulatory setting. Cancer Nurs 38(2):111-117.

Kopp B, Schierl R, Nowak D [2013] Evaluation of working practices and surface contamination with antineoplastic drugs in outpatient oncology health care settings. Int Arch Occup Environ Health 86:47-55.

Survey and report

To request a copy of this survey, please email

Journal articleexternal icon

(The free full text article will be available in Pub Med Central one year after the article has published)

Page last reviewed: July 13, 2017