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P22 - Mobilizing a Mountain: How to Prepare for Compliance to USP in the Non-Oncology Ambulatory Care Environment

The National Institute for Occupational Safety and Health (NIOSH) estimates that 8 million health care workers who handle or administer hazardous drugs (HDs) may be exposed in the workplace. Exposure to HDs can cause short-term or long-term side effects including skin disorders, infertility, and/or cancer. Although guidelines on handling and administering HDs have been published, there were previously no enforceable standards. USP General Chapter Hazardous Drugs – Handling in Healthcare Settings specifies practice and quality standards to promote patient and employee safety, as well as environmental protections. USP , which was initially published in 2014 and finalized in 2016, was set to be enforceable on December 1, 2019, by The Joint Commission® and state pharmacy boards. However, it has been delayed as the process of HD compounding is still being finalized. Once this has been finalized, USP will be enforceable. In the interim, health care organizations can choose to adopt USP standards, which has been encouraged by USP® to ensure safe work practices.

Non-oncology ambulatory care environments will need to make significant practice changes to be in compliance with USP . New workflows and practices need to be developed including wearing personal protection equipment (PPE), using a closed-system transfer device and safely cleaning up a spill. Although the oncology environments will also be impacted, the standards are not new as they are based, at least partly, on the Oncology Nursing Society guidelines. Therefore, in these environments, practice changes have already started to take place.

The objective of this poster is to describe how non-oncology ambulatory care environments can prepare for USP . The first step in being successful will be to create an interdisciplinary team with oncology, inpatient, occupational health, and pharmacy. Partnering with these disciplines allows for individual expertise to inform how to safely implement USP . The second step will be development of an educational plan for clinical staff (RNs, LPNs, MD/APPs) administering and cleaning HD spills. In addition, an educational plan will need to be developed for ambulatory care leadership to guide them on the supplies they will need (e.g., PPE, HD waste containers, spill kits, etc.), as well as the operational workflows to ensure employee and patient safety. The final step in successfully preparing for USP in the non-oncology ambulatory care environments will be to develop resources to support the implementation of the program (e.g., skill validations, online learning tools, etc.).

At our academic institution, the ambulatory care environment includes over 50 non-oncology ambulatory care clinics, comprising of approximately 150 clinical staff administering HDs. Preparing to implement USP standards will require substantial change in the non-oncology ambulatory care environments. In order to be successful, it will require working as an interdisciplinary team to develop educational plans, implementing safe work practices, and developing resources to support clinical staff and ambulatory care leadership to comply with USP standards.

Learning Objective:

  • After completing this learning activity, the participant will be able to assess innovations being used by other professionals in the specialty and evaluate the potential of implementing the improvements into practice.


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