Hazardous medicinal products (HMPs) are widely used in nursing, for example in cancer treatment.
The RCN recognises that HMPs are vital for patient care and must be administered. However, more needs to be done to ensure nurses who handle these medicines are adequately protected.
Louise Church, RCN Health, Safety and Wellbeing Senior National Officer, is helping to raise awareness of what HMPs are, and is leading the RCN’s work to lobby for UK-wide guidance and minimum standards of control to protect nursing staff.
She’s answered some key questions so you can better understand HMPs.
What are HMPs?
HMPs refers to any pharmaceutical substance that can cause specific health effects and harm to nursing staff if they are exposed to them. Currently the UK doesn’t have an accepted definition, but in the EU for example, an HMP is defined as something which is reprotoxic, carcinogenic or mutagenic.
HMPs include cytotoxic and cytosatic drugs used in cancer treatment, immunosuppressants for autoimmune conditions like rheumatoid arthritis, lupus and HIV, and organ transplantation medicines. Some hormonal therapies for the treatment of breast or prostate cancer, certain antivirals and antibiotics are also HMPs.
How could I be affected?
If you’re using HMPs to treat patients – which includes preparing, handling, administering and disposing of them – you could be exposed to their effects as well, if robust health and safety controls are not in place.
For example, you might think of nurses working in cancer care administering systemic anti-cancer therapy (SACT). They’re at risk of exposure to HMPs due to the potential environmental contamination of surfaces and IV bags.
Exposure to HMPs can result in skin and respiratory irritation, hair loss, nausea, headaches, and allergic reactions. HMPs can also lead to organ, respiratory, and blood toxicity. As nursing is a predominantly female workforce, there are also potential reproductive cycle risks, infertility and birth defects to be aware of.
Are there any groups who are particularly vulnerable?
Inadequate controls can further increase risks for immunocompromised individuals and those with allergies or respiratory/skin conditions.
Also, with HMPs categorised as reprotoxins, there’s a heightened risk for those who are pregnant, breastfeeding or planning to conceive.
What are the problems we need to solve?
The UK doesn’t have an accepted definition of what an HMP is, or an official list of hazardous medicinal products to use as part of the risk assessment process. We’re behind other countries and areas in this way. For instance, the USA and the EU have both published definitions and lists of hazardous drugs.
The RCN is pushing for a UK definition of HMPs; for a detailed list of hazardous medicinal products to be adopted and embedded in health and safety practice; and for rigorous guidance to be developed, outlining the minimum standards of control on the lifecycle of HMPs, from delivery, storage, preparation, administration to disposal. We need employers to be required to keep a register of staff who work with HMPs.
- There's more detail in the RCN position statement on HMPs
What does my employer have to do to keep me safe?
Detailed risk assessments must be carried out of any areas, tasks and activities where HMPs are stored, prepared, handled, administered and disposed of. Consideration must also be given to patients treated with HMPs who are being cared for by nursing staff, for example, in other wards, in the community and in care homes.
Risk assessments should outline controls to minimise the risk of exposure for staff. Employers are required to do this under the Control of Substances Hazardous to Health regulations (COSHH).
What additional protections would you like to see?
We want guidance specifically for HMPs, which sets out the minimum standards of control, beginning in cancer settings – where nursing staff are working with a complex and diverse range of HMPs daily.
This requires risk assessment by employers including environmental monitoring of the patient and nursing spaces where the drugs are used. This is done through methods like wipe testing, and simulation events, which help to continuously improve by identifying contamination and adapting current practice.
How can I protect myself?
“There’s a systematic approach called a ‘hierarchy of controls’, which you can use to protect yourself,” Karen says.
The hierarchy of controls is part of the risk assessment process, as a requirement of the COSHH regulations. Nursing staff can refer to the hierarchy to raise questions about what is being done to protect them.
These are defences workplaces can use against HMPs, ranked from most effective and reliable:
- Elimination – physically remove the hazard.
- Substitution – replace the hazard.
- Engineering controls – isolate people from the hazard. In oncology this would include using totally enclosed systems, for example closed system transfer devices (CSTDs), which are designed to prevent the escape of hazardous drugs.
- Administrative controls – change the way people work.
- Personal protective equipment (PPE) – protect staff with PPE.
Karen’s research into HMPs sheds light on cancer nursing staff’s awareness of the dangers, their use of CSTDs, what kind of PPE is used, and staff’s perceived health effects from HMPs.
More data is needed on staff who are working with dangerous drugs, she says. The USA has recently started a register of nursing staff administering chemotherapy.
“Part of the problem is we can’t capture the extent of the health effects from working with HMPs,” Karen says.
“This means that health effects remain anecdotal and subject to being attributed to other environmental or individual causes.”
Managing HMPs: a success story
When I started in my role, lead cancer nurses at each site understood the importance of safety around HMPs – but there was no consistency across the organisation.
One of the biggest changes was implementing wipe testing, which allowed us to show the benefits of controlling HMPs. In one of our hospitals, early results showed high surface exposure to certain drugs. After introducing our controls, exposure dropped to trace levels or zero. We now test annually to monitor effectiveness and guide staff training.
We also standardised PPE across systemic anti-cancer therapy centres and introduced CSTDs (the engineering controls Karen mentions above). We upgraded our intravenous pumps to allow safe bolus delivery and switched to heat-sealing for waste, reducing bin use.
For certain high-risk drugs, where we have to reconstitute – such as dextraxonzane for extravasation – we now use full PPE: gowns, double gloves, visors and masks.
My team feels safer knowing we’ve put in these measures
Fortunately, we didn’t have a huge amount of pushback to all these changes from staff. They knew that my predecessor and I were employed in this role because there was a gap in the knowledge of handling these sorts of medicines, so they listened to us.
As with any new initiative, cost implications are an important consideration. At first glance, the purchase of new equipment appeared more expensive. But our findings show that when a closed system is used correctly, larger saline flush bags can be utilised, which are more cost-effective than multiple smaller bags typically required during a treatment cycle.
For example, if a patient receives three different SACT medicines, using one saline bag instead of three can result in a cost saving of approximately £1 per patient per cycle.
While not formally measured, there is also potential for time savings, as each saline bag requires a two-nurse check. Reducing from three checks to one further improves efficiency.
These drugs work at a cellular level. They alter DNA and can linger on surfaces or become airborne. If there’s any risk of HMPs to staff, why wouldn’t we act?
My team feels safer knowing we’ve put in these measures. Staff value the wipe testing results, as these provide reassurance they’re taking the right steps to protect themselves, as well as porters, housekeeping teams, patients, and their families.
RCN action on HMPs
- We’re calling on UK governments to produce a definition of HMPs, to adopt or endorse an existing indicative list, such as one from the EU or USA. We also want the Health and Safety Executive to develop robust guidance and minimum standards for the lifecycle of HMPs. Find out more in our position statement.
- At an RCN-arranged parliamentary reception, we told politicians about the risks of HMPs and what urgently needs to change to ensure the safety of nursing staff.
- You can get involved by speaking to your employer and asking questions to find out what they’re doing to protect you from HMPs.
- Learn more by reading Exploring Safe Practice When Handling Cytotoxic Drugs: Findings From Survey Of UK Cancer Nurses. This open-access article, co-authored by Dr Karen Campbell, makes recommendations about the handling of some forms of HMPs.
