NIOSH Study Finds Measures Lacking for Compounding Antineoplastic Drugs

September 1, 2015
NIOSH Update:

Contact: Nura Sadeghpour (202) 245-0673

A new article from the National Institute for Occupational Safety and Health (NIOSH) found that recommended safe handling practices for compounding antineoplastic (or chemotherapy) drugs are not always followed in healthcare settings. This study was published in the September issue of the Journal of Occupational and Environmental Hygiene and is currently available online.

Results in this article are derived from the 2011 Health and Safety Practices Survey of Healthcare Workers, the largest federally-sponsored survey of healthcare workers in the U.S. which addresses safety and health practices relative to use of hazardous chemicals. This paper presents findings on current engineering and administrative control practices, personal protective equipment (PPE), and barriers to using recommended PPE during preparation of antineoplastic drugs by nurses, pharmacists and pharmacy technicians.

“The adverse health effects associated with chemotherapy drugs are well documented, and it is incumbent upon healthcare employers and workers to acknowledge these risks and put recommended guidelines into practice.” said NIOSH Director John Howard, M.D. “Using the hierarchy of controls is a proven strategy to achieve the safest possible workplace.”

Findings show lack of universal adherence to precautionary guidelines and other best practices by employers and healthcare workers. Below are examples of practices which may increase exposure risk to antineoplastic drugs, expressed as percent of nurses and pharmacy practitioners, respectively:

  • Not always wearing two pairs of chemotherapy gloves (85%, 47%) or even a single pair (8%, 10%). The most common reasons for not wearing chemotherapy gloves were “skin exposure was minimal”; the gloves were “too uncomfortable or difficult to use” and were “not provided by employer.”
  • Not always using closed system drug-transfer devices (75%, 53%); or either a biological safety cabinet or isolator (9%, 15%).
  • Lack of medical surveillance programs (61%, 45%).
  • Not always wearing the recommended gown (38%, 20%). The most common reasons for not wearing protective gowns were “not part of our protocol”; “an engineering control was being used”; and “skin exposure was minimal.”
  • Intravenous (I.V.) lines sometimes/always primed with antineoplastic drug (19%, 30%).
  • Lack of hazard awareness training (9%, 13%), safe handling procedures (20%, 11%).
  • Skin contact with antineoplastic drug (11%, 4%).

Some of the reasons for not using chemotherapy gloves and protective gowns (i.e., skin exposure was minimal, not part of our protocol) suggest a mindset that incidental skin contact with antineoplastic drugs are acceptable and part of the job.

Although authoritative safe handling guidelines (ASHPexternal icon, NIOSHpdf icon, ONSexternal icon, OSHAexternal icon) have been available for nearly three decades, recommended exposure controls were not always used. This is highly noteworthy considering that there is no safe level of exposure to cancer-causing agents. Better risk communication is needed to ensure that employers and nurses, pharmacists, and pharmacy technicians are fully aware of the hazards.

Employers need to ensure that workers who compound antineoplastic drugs are initially and periodically trained; safe-handling procedures reflecting national guidelines are in place and support for their implementation is understood; engineering controls and PPE are available and workers know how to use them; and medical surveillance, exposure monitoring and other administrative controls are in place. Workers can seek out training, understand and follow facility procedures, be role models for junior staff, ask questions and report any safety concerns.

Using data obtained from the same survey, NIOSH previously reported on healthcare workers who administer antineoplastic drugs that also found recommended safe handling practices were lacking: icon.

The findings from this survey are expected to help NIOSH, partners, employers and healthcare workers better understand current health and safety practices relative to working with hazardous chemical agents, identify gaps in current knowledge about those practices, and, in collaboration with partners, design further research for addressing those gaps. To access the current article online, visit: icon.

NIOSH is the federal agency that conducts research and makes recommendations for preventing work-related injuries, illnesses and deaths. To learn more about healthcare safety and health, visit: More information can be found at

Page last reviewed: September 1, 2015