ABSTRACT

Purpose of this EBP was to identify exposure risk to hazardous drugs for nurses, patients, and ancillary staff at the at the ambulatory infusion centers, VGPCC research infusion clinic, and in certain areas of the hospital. After an assessment at HonorHealth (HH) it was identified that a drift in best practice recommendations by the Oncology Nursing Society had developed due to inconsistent availability of supplies, unstable workforce, change in nomenclature from chemotherapy to hazardous drugs (HD), and program expansion.

A review of the literature was performed to identify best practice for safe handling of hazardous drugs (aka chemotherapy). The PICO question: HonorHealth (HH) Oncology nurses administering hazardous drugs, how does education of best practice for safe administration of hazardous drugs, compared to current practice for personal protective equipment (PPE) help adherence to best practice guidelines for PPE use during hazardous drugs administration.

Each site was evaluated for readiness of the requirements of PPE for safe handling. Policies were created and updated to reflect best practices. Education was developed and disseminated to all staff and built into the new hire orientation.

Outcomes were tracked and reported to bedside/chairside staff at huddle. Staff were recognized for excellent performance and units/clinics were celebrated when outcomes were achieved and sustained. A sustainability plan was created to prevent practice drift in the future. Culture change was identified at HH with the nomenclature from Chemotherapy to Hazardous Drugs, across the continuum. Practice barriers continue to be identified and reported for improvement.