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Safe handling of cytotoxic drugs in the workplace

Cytotoxic drugs are used widely in healthcare settings as well as in the community in the treatment of cancers as well as other diseases.  

This page provides information to employers and employees on the occupational hazards associated with cytotoxic drugs and the precautions to take when handling them. It is not aimed at manufacturers of cytotoxic drugs.  

Cytotoxic drugs (sometimes known as antineoplastics) describe a group of medicines that contain chemicals which are toxic to cells, preventing their replication or growth, and so are used to treat cancer. They can also be used to treat a number of other disorders such as rheumatoid arthritis and multiple sclerosis. Once inside the body, their action is not generally tightly targeted, and they can produce side effects both to the patients and others who become exposed.

They are used in range of settings including; hospitals, specialist oncology units, hospices, care homes, charitable organisations, and domestic homes. They may also be used in veterinary clinics.  

What is the risk?

The toxicity of cytotoxic drugs means that they can present significant risks to those who handle them.  Occupational exposure can occur when control measures are inadequate. Exposure may be through skin contact, skin absorption, inhalation of aerosols and drug particles, ingestion and needle stick injuries resulting from the following activities:

Inadequate control measures could lead to;

Who is at risk?

Anyone working with patients (or animals) receiving cytotoxic drugs is at risk of exposure.  This therefore includes pharmacists, pharmacy technicians, medical and nursing staff, laboratory staff, and others.  Veterinary practitioners are equally at risk when using cytotoxics in animals. Appropriate control measures must be in place to protect them all.

What you need to do

Cytotoxic drugs are hazardous substances, as defined by the Control of Substances Hazardous to Health Regulations 2002 (COSHH).

Under COSHH, employers must assess the risks from handling cytotoxic drugs for employees and anyone else affected by this type of work, and take suitable precautions to protect them.

More specific information can be found in the COSHH Approved Code of Practice (ACOP). You should:

Employees have a legal duty to take care of their own health and safety and that of others affected by their actions. They must make full and proper use of control measures put in place by the employer. In addition, they should cooperate with their employer, so they can comply with any legal duties placed on them.

Control of exposure

Measures to control exposure should be applied in the following order:

The broad measures described above will include more specific controls, such as:

Personal Protective Equipment

Personal protective equipment (PPE) should be provided and used wherever risks cannot be adequately controlled in other ways. PPE should be selected based on your risk assessment. It is important that the PPE offers adequate protection for its intended use. Employees must be trained in the use of PPE and it must be adequately maintained and stored.

Monitoring exposure in the workplace

Monitoring includes any periodic test or measurement which helps confirm the effectiveness of controls. Under COSHH, monitoring is necessary when:

In accordance with the COSHH ACOP, monitoring is normally necessary where there is potential for exposure to carcinogenic compounds. HSE publication, Biological monitoring in the workplace: A guide to its practical application to chemical exposure, provides further information.

Occupational Health Services

Where appropriate, using an occupational health service can help you identify risks, get advice on suitable precautions and control measures, and provide services such as;

Dealing with spillages and contamination

Clear procedures, which staff who handle cytotoxics or contaminated waste should be familiar with, must be in place for dealing with spillages or contamination of people or work surfaces. Measures to prevent or contain spillages should be used at all times. Any spillages that do occur should be dealt with promptly.

Waste disposal

Procedures must be in place for the safe disposal of waste. All relevant staff should be familiar with these procedures. Excreta from treated patients may contain unchanged cytotoxic drugs or active metabolites.

Information, instruction and training

Employees handling cytotoxic drugs must be given suitable and sufficient information, instruction and training, relevant to their work. Employees must be made aware of the risks of working with cytotoxics and the necessary precautions.

Reporting incidents

Under the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013 (RIDDOR) the accidental release of any substance which may cause a major injury or damage to health is classed as a dangerous occurrence and should be reported. However, a small spillage of a cytotoxic drug which is well contained and easily dealt with is not reportable. Spillage of a large amount, to which people could have been exposed, is reportable.

Further information

The sixth edition of the COSHH Approved Code of Practice and guidance provides practical advice to help duty holders comply

Revised guidance for the safe delivery of systemic anti-cancer therapy published by the Scottish Government

Susan Goodin Safe Handling of Oral Chemotherapeutic Agents in Clinical Practice: Recommendations: From an International Pharmacy Panel. Journal of Oncology Practice January 2011

Christopher R Friese Structures and processes of care in ambulatory oncology settings and nurse-reported exposure to chemotherapy BMJ Quality and Safety August 2011

2016-01-10