[HAZARDOUS DRUG SAFETY & HEALTH PLAN: PREPARATION, ADMINISTRATION AND
DISPOSAL OF CYTOTOXIC AGENTS]{.underline}

1\. [PURPOSE]{.underline}:

To state medical center policy and establish standardized procedures for
safe preparation, handling, administration, and disposal of cytotoxic
materials (carcinogens).

2\. [POLICY]{.underline}:

a\. Verification of chemotherapy orders will be done by a chemotherapy
certified RN in the setting where the chemotherapy is to be initiated.
Example: when the patient's chemotherapy is started in the outpatient
setting and then completed in the inpatient setting, the ambulatory
chemotherapy certified RN will verify the orders. When the chemotherapy
is initiated in the inpatient setting, the inpatient chemotherapy
certified RN will verify the orders.

b\. The physician or fellow ordering chemotherapy is to be called
regarding verification or clarification questions. If the ordering
physician cannot be reached, the attending physician is to be called. If
neither physician can be reached, the orders are to be held until they
can be clarified. Any change, verification, or clarification of
cytotoxic orders received by the registered nurse or pharmacist will be
written on the Doctor's Orders form.

c\. Inpatient chemotherapy orders must be received by 4:00 p.m. to be
initiated that day, except for emergencies.

d\. Pharmacy technicians and pharmacists may prepare admixtures for
cytotoxic agents following completion of an orientation in safe
management and handling of cytotoxic agents, and only in an appropriate
biological safety cabinet (BSC). Pharmacists will double check any
cytotoxic IV admixture prepared by a pharmacy technician.

e\. [Qualifications for cytotoxic agent administration]{.underline}.

\(1\) Parenteral chemotherapeutic agents will be administered by a
qualified physician or a registered nurse certified in chemotherapy.

\(2\) A qualified physician or a registered nurse certified in
chemotherapy will also administer investigational cytotoxic agents or
those with vesicant properties.

\(3\) Any cancer chemotherapeutic agent which is ordered to be given by
intravenous push (IVP) will only be given by the hematology/oncology
clinical nurse specialist, a hematology/oncology nurse clinician, or a
qualified physician.

\(4\) Bladder instillation of chemotherapeutic agents will be
administered by a urology physician assistant, a urology registered
nurse competent in chemotherapeutic agents, or a urology physician.

f\. Environmental contamination and exposure of personnel to these
agents will be minimized through clear labeling and appropriate handling
and disposal.

g\. Permanent records listing names of employees preparing,
administering, and/or disposing of anti-neoplastic agents will be
maintained.

h\. All employees working with cytotoxic agents will receive special
training before being assigned to prepare, administer, and/or dispose of
cytotoxic agents. Each service is responsible for training staff who
will handle cytotoxic agents.

i\. Pharmacy Service, the Industrial Hygienist, Patient Care Service,
and the Triage Area (B-112) will maintain Material Safety Data Sheets
(MSDS) for each commercially available cytotoxic drug used in this
medical center.

j\. Employees who are pregnant, lactating, or have a written statement
from a physician providing medical reasons why they should not be
exposed to cytotoxic agents will not prepare or administer these, or
handle spills involving these drugs.

k\. Employees who prepare intravenous chemotherapy will have an annual
anti-neoplastic health screening administered by Employee Health.

l\. Non-injectable anti-neoplastic or hazardous dosage forms will be
handled, dispensed, and administered to prevent potential personal
exposure.

3\. [PROCEDURES]{.underline}:

a\. [Central Supply Employees]{.underline}.

\(l\) Purchase requests for chemotherapeutic agents from Pharmacy
Service will include \*ANTI-NEOPLASTIC\* under the long description of
the item.

\(2\) Pharmacy Service will also request an MSDS if not currently on
file. A copy will also be provided to areas where the cytotoxic drug
will be administered.

\(3\) If contents of packages containing cytotoxic material have been
damaged, the container will immediately be resealed and placed in the
appropriate chemotherapy waste receptacle.

\(4\) If material has leaked out of the shipping container, access to
the area will be strictly limited to authorized personnel; these
employees will wear appropriate protective clothing e.g., gowns, gloves,
goggles and a N95 respirator. Maintenance employees will then be
notified and clean the spill (see c. Spills).

\(5\) The Central Supply leader will be notified immediately by
warehouse staff upon receipt of damaged cytotoxic drugs. All contents of
contaminated containers are considered unacceptable for use by the VA.

b\. [Processing cytotoxic orders]{.underline}.

\(1\) The physician writes the orders for cytotoxic drugs to include the
drug, dose/m2, dose modification % (if applicable), route of
administration, and frequency of administration.

\(2\) A chemotherapy certified registered nurse verifies the dose
calculation, route, and schedules for administration as compared to the
treatment protocol as well as the orders for antiemetics and special
instructions before orders are sent to pharmacy for processing. The RN
also verifies that a consent for cytotoxic therapy has been signed.

\(3\) The pharmacist reviews the physician orders for cytotoxic drugs to
verify dose calculation, route, and schedule, comparing to the treatment
protocol, as well as orders for antiemetics and special instructions
before orders are processed.

c\. [Pharmacy Antineoplastic Preparation Procedures]{.underline}.

\(l\) [Pharmacy Employee Safety]{.underline}.

\(a\) Access to the compounding area will be limited to only the
necessary authorized personnel.

\(b\) All cytotoxic admixtures will be performed in a Class II, BSC. No
other intravenous admixtures will be prepared in the BSC designated for
cytotoxic agents.

[1]{.underline} Cytotoxic admixtures will be performed in the BSC with
the view screen at the recommended access opening.

[2]{.underline} Routine infection control and maintenance will be
followed for the BSC.

[3]{.underline} The BSC blower will run continuously 24 hours a day.

[4]{.underline} The BSC will be decontaminated on a regular schedule and
whenever there is a spill. Decontamination will consist of applying a
suitable cleaner to all interior surfaces of the BSC, scrubbing, and
rinsing thoroughly with sterile water. Work surfaces will be disinfected
with 70% alcohol before beginning any aseptic admixture preparation.

[5]{.underline} To ensure proper functioning, the BSC will be certified
by a competent contractor semi-annually or whenever the equipment is
moved or repaired.

\(c\) Two pair of latex, unpowdered surgical gloves and a protective,
disposable, lint-free, low permeability gown with a closed front, long
sleeves and closed cuff will be worn at all times while manipulating
chemotherapy or performing chemotherapy admixtures. When double gloving,
one glove should be placed under the gown cuff and one over. When using
powdered latex surgical gloves, all powder should be washed off the
outside of the outer glove before any admixture is prepared. All
potentially contaminated garments will not be worn outside of the
compounding area.

\(d\) Hands will be washed thoroughly before gloving and after gloves
are removed.

\(2\) [Preparing Materials for Entry into the BSC]{.underline}.

\(a\) The interior surfaces of the BSC will be cleaned using 70% alcohol
and disposable gauze pads before preparing any drug admixture at the
beginning of each day.

\(b\) All bulk fluids and cytotoxic agents will be removed from
packaging before entry into the hood with the exception of needles,
syringes, and alcohol pads.

\(3\) [Admixture]{.underline}.

\(a\) Care will be taken to prevent the development of positive pressure
with vials. This may be accomplished by using vented needles, aerosol
protection devices, hydrophobic venting filters or by removing solution
prior to injecting air.

\(b\) Cytotoxic agents packaged in glass ampules will be opened by
wrapping a sterile gauze pad around the neck and breaking sharply. The
contents should be removed using a filter straw or filter needle.

\(c\) The filter straw or needle should be changed to a needle and any
overfill returned to the glass ampoule. Prior to disposal, the contents
of the ampoule will be removed with a syringe and then the syringe
capped before disposal.

\(d\) No more than 50% of the stated volume of a bulk solution may be
added to that solution (i.e., no more than 50 ml can be added to a 100
ml bag). If more than 50% of a stated volume must be added, first remove
the necessary fluid from the vehicle and then add the cytotoxic agents.

\(e\) Syringes prepared by the central pharmacy will never be more than
two-thirds full. The largest syringe disposed of will be a 30ml syringe.

\(f\) When reconstituting Mechlorethamine (nitrogen mustard), vent the
vial with a venting filter (i.e., Millex FG 0.2 micron). This will
equalize the pressure in the vial and minimize exposure due to leakage
of the vial contents under high pressure. Spills of unused
mechlorethamine must be inactivated by sodium thiosulfate/sodium
bicarbonate solution. Add 100 ml. water to the pre‑measured sodium
thiosulfate 5 gm. and sodium bicarbonate 5 gm. container to prepare a 5%
of each solution. Solution decomposes upon standing, therefore,
solutions of the drug should be prepared immediately before use.

\(4\) [Labeling and Packaging of Parenteral Chemotherapeutic
Agents]{.underline}.

\(a\) All parenteral chemotherapeutic agents will be processed in the
intravenous computer program and labeled with the patient\'s name, ward,
instructions for administration, drug name, drug dose, volume of drug,
drug strength (if appropriate), date and time of dose, expiration date,
initials of pharmacist/technician preparing and checking the medication,
and any appropriate auxiliary warning statement or storage directions.

\(b\) In addition to the above label, a distinctive warning label
\"CAUTION: CHEMOTHERAPY ‑‑ Handle with gloves ‑‑ Dispose of properly\"
will be on all intravenous bags and on the outside of the zip-lock bags
containing intravenous chemotherapeutic bags and syringes.

\(c\) Vincristine doses will have a label stating \"Do Not Remove
Covering until the moment of injection. Fatal if given intrathecally.
For Intravenous Use Only\" on the outside of the zip-lock bag.

\(d\) If the agent is a known vesicant or irritant, this should be
clearly indicated on the label, \"Avoid Extravasation\". The following
drugs must be so labeled:

[1]{.underline} Vesicant: Defined as an \"agent capable of causing or
forming a blister and causing tissue destruction.\"

Commonly used agents with vesicant properties (this list is not all
inclusive):

Dactinomycin (Actinomycin D) Vinblastine (Velban)

Daunorubicin (Cerubidine) Vincristine (Oncovin)

Doxorubicin (Adriamycin) Vinorelbine (Navelbine)

Mitomycin C (Mutamycin) Mechlorethamine (Nitrogen Mustard)

Idarubicin (Idamycin)

[2]{.underline} Potential vesicant: Defined as an agent capable of
vesicant properties if a large amount of drug is extravasated or if the
drug is in a concentrated form, otherwise acts as an irritant.

Cisplatin (if \> 20ml. of 0.5mg./ml. extravasated)

Mitoxantrone (Novantrone)

Paclitaxel (Taxol)

[3]{.underline} Venous irritant: Defined as an \"agent capable of
producing venous pain at the site and along the vein, with or without an
inflammatory reaction.\"

Commonly used cancer chemotherapeutic agents with venous irritating
properties which staff nurses may administer (this list is not all
inclusive):

Carmustine (BCNU) Doxorubicin liposome

# Dacarbazine (DTIC) Bleomycin

# Carboplatin Ifosfamide

> Etoposide (VP-16) Cisplatin (if less than 20ml. of 0.5mg./ml
> extravasated)

Teniposide (VM-26)

\(e\) All chemotherapeutic intravenous push doses will be prepared in a
luer lock syringe.

\(f\) All cytotoxic agents in syringes or in intravenous bags will be
sent to the floor in a zip‑lock bag clearly marked as a cytotoxic agent.

\(g\) All Mechlorethamine (nitrogen mustard) intravenous push doses will
be accompanied by a \"sodium thiosulfate extravasation kit,\" which
includes directions for use.

\(5\) [Labeling and packaging of non-injectable cytotoxic and hazardous
dosage forms]{.underline}.

\(a\) Drugs designated as cytotoxic or hazardous will be labeled or
otherwise identified to prevent improper handling.

\(b\) Tablet and capsule forms of these drugs will not be placed in
automated counting machines, which may introduce powdered contaminants
into the work area.

\(c\) During routine handling of cytotoxic drugs and contaminated
equipment, personnel should wear one pair of gloves.

\(d\) Contaminated equipment should be cleaned initially with gauze
saturated with water and further cleaned with detergent and rinsed. The
gauze and rinse should be disposed of as contaminated waste.

\(e\) Disposal of all oral or topical cytotoxic drugs will be in a
cytotoxic waste container.

d\. [Administration of Chemotherapeutic Agents]{.underline}. (See
attachment A-1).

\(1\) Infusion of IV chemotherapy will be monitored by a registered
nurse certified in chemotherapy drug administration.

\(2\) Employees who are pregnant or lactating, or have a written
statement from a physician providing medical reasons why they should not
be exposed to cytotoxic agents, will not administer these agents.

\(3\) Personnel will wear disposable, lint-free, low permeability
long-sleeved gowns that are snug fitting at the wrist, and should double
glove with latex gloves or with a single equal millage latex glove,
e.g., Bio Safety, when handling cytotoxic agents. Hands should be washed
before gloving.

\(4\) Intravenous infusion sets should be luer lock, if possible.

\(5\) To avoid possible contact with the drug, first connect the
chemotherapeutic intravenous bag to the secondary line or \"piggyback\"
tubing. Attach access pin and safesite valve to end of secondary tubing.
Then attach the secondary tubing to the main intravenous tubing, unless
already connected. Purge air from the secondary line by holding the bag
lower than the main intravenous bag and allowing fluid to flow back
through the secondary line tubing.

\(6\) Intravenous chemotherapy infusions should be watched for leakage
during administration.

\(7\) Remove gown and gloves after use and dispose of in the cytotoxic
waste container.

\(8\) Hands should be thoroughly washed after removing gloves.

\(9\) Personnel performing patient care are at risk if in contact with
blood and body fluids during administration of chemotherapy and for 48
hours following treatment. Protective gown and latex gloves must be worn
as appropriate. A portable chemo waste receptacle will be placed in the
patient's room during the chemo precaution period.

\(10\) Patients receiving intravenous chemotherapy will remain on the
patient unit unless otherwise instructed.

\(11\) Patients receiving IV chemotherapy will be clearly identified on
the Kardex with the start and stop date of precaution so employees can
perform their duties in accordance with proper safety precautions.

\(12\) All nursing personnel handling cytotoxic agents should keep a
personal record of each contact with date, time, patient name, and
nature of contact.

\(13\) If a cytotoxic tablet must be crushed to administer to a patient,
the tablet will be placed in a small sealable plastic bag and crushed
with a spoon or pestle. Caution should be used to not break the plastic
bag.

e\. [Management of Extravasation]{.underline}.

\(1\) [Definitions]{.underline}.

\(a\) Vesicant extravasation (see attachment A-1): The leakage of a drug
into the subcutaneous tissue that is capable of causing pain, necrosis,
and/or sloughing of tissue.

\(b\) Delayed extravasation: Same as vesicant extravasation except
symptoms occur within 48 hours after drug administered.

\(c\) Flare: A local allergic reaction without pain, but usually
accompanied with red blotches along the vein, subsiding within 30
minutes with or without treatment.

\(2\) An extravasation kit with the following drugs/equipment is to be
available on the unit. The specific antidote for the vesicant(s) should
be obtained from pharmacy prior to administration so that it is readily
available. The kit should be brought to the bedside to be available for
immediate use when administering IVP vesicant chemotherapeutic agents.

Extravasation Kit:

\(a\) 2-10ml syringes

\(b\) 2-5ml syringes

\(c\) 10ml sterile water

\(d\) 10ml sterile saline

\(e\) 4-25g. Needles

\(f\) 4-19g. Needles

\(g\) alcohol wipes

\(3\) [Assess for subjective/objective signs of an
extravasation]{.underline}.

\(a\) Subjective: complaints of burning at/around IV site or along vein
track, pain at IV site, non-specific discomfort.

\(b\) Objective: no blood return, swelling/bleb at IV site,
slowed/stopped flow rate, blistering, red streaking along vein track.

\(4\) Stop infusion, leave needle in place. (See attachment A-2).

\(5\) Disconnect the needle/cannula from the IV tubing and attach a 10ml
syringe to the butterfly tubing or extension set.

\(6\) Withdraw as much fluid (drug, tissue fluid, blood) through the
needle as possible. Administer antidote if indicated; provide site care
as appropriate.

\(7\) Notify inpatient house officer and appropriate Hematology/Oncology
Fellow.

\(8\) Document the following on the patient\'s medical record:

> \(a\) Date and time

\(b\) Type of venous access (needle type and size) and insertion site

\(c\) Number of venipuncture attempts and location

\(d\) Drug(s)

\(e\) Drug sequence and administration technique

\(f\) Approximate amount of drug extravasated/or suspected of
extravasating

\(g\) Patient complaints and statement

\(h\) Nursing management of extravasation and physician notification

\(i\) Appearance of site

\(j\) Follow-up instruction given to patient

\(9\) Complete adverse drug reaction Medwatch form for extravasation or
suspected extravasation.

\(10\) Flow diagrams for treating drug extravasation can be found in the
Nursing Policy and Procedure for Chemotherapy Administration. (See
attachment A-2).

f\. [Spills]{.underline}.

\(1\) [Direct contact with cytotoxic agents]{.underline}.

\(a\) If spilled cytotoxic material comes in contact with a person\'s
skin or clothing, the involved gloves or disposable gown should be
removed immediately and discarded in the same manner as other
chemotherapeutic waste materials. The clothing will be identified by
owner name/location and processed as isolation linen.

\(b\) For skin exposure, immediately wash the affected area thoroughly
with soap (not germicidal) and water then dry.

\(c\) For eye exposure, immediately flood the affected eye for 15
minutes with water or eyewash designated for that purpose. (Medical
attention should be obtained immediately for a post-exposure
examination.)

\(d\) Spills involving Mechlorethamine (nitrogen mustard) should be
treated by flushing the area of skin contact with large amounts of water
followed with a flush of sodium thiosulfate 2.5% solution to the area.
Medical assistance should be obtained immediately for a post-exposure
examination.

\(e\) Accidents involving skin or eye contact should be reported and
documented in accordance with Policy Memorandum 00-6, Appendix G
governing work related injuries.

\(2\) [Small Spills]{.underline}.

\(a\) Small spills are defined as those involving under 5 ml. of liquid
or 5 gms. of powder/solid cytotoxic material.

\(b\) 4\"x4\" gauze pads are available in the work area for use in
cleaning spills occurring within the BSC.

\(c\) For a small spill occurring outside of the BSC, clearly define and
mark off the area and keep traffic to a minimum until the area is
cleaned.

\(d\) Personnel involved in cleaning the spill will wear double latex
gloves and disposable gowns before attempting to clean the spill.

\(e\) Care should be taken to localize the spill. Absorb the spill using
4\"x4\" gauze pads; solids should be wiped with a wet absorbent gauze.

\(f\) After absorption of the spill, clean the area thoroughly three
times using a detergent solution followed by clean water. All cleaning
materials will be disposed of in the appropriate cytotoxic waste
container, along with any broken glass fragments which should first be
placed in a small cardboard or plastic container.

\(g\) Glassware or other contaminated reusable items should be placed in
a plastic bag and washed in a sink with detergent by a trained employee
wearing double surgical latex gloves.

\(h\) After the spill has been cleaned, the manipulator should remove
both pairs of gloves, wash hands, and use new gloves before continuing
with additional admixture or administration.

\(i\) Patients who are sent home with chemotherapy will also receive
instructions from medical care staff regarding spills.

\(3\) [Large Spills]{.underline}.

\(a\) Large spills are defined as those involving greater than 5 ml or 5
gms of cytotoxic material. Maintenance staff will be responsible for
large spills when notified.

\(b\) Personnel involved in cleaning the spill will wear two pair of
latex gloves, N95 respirator, disposable gown, eye protection, and shoe
coverings.

\(c\) The area involved should be clearly identified and traffic should
be minimized until the spill is cleaned.

\(d\) A cytotoxic or chemotherapy spill kit with the following contents
should be used to assist in cleaning the spill: two pair latex gloves,
safety glasses, two spill‑proof absorptive mats, two absorbent towels,
two large disposable bags, a disposable gown, shoe coverings and caution
labels.

\(e\) The spill should be completely absorbed using spill control pads
(available in spill kits), or if powder is involved, with dampened
absorptive pad, while paying attention to localizing the spill and not
generating aerosols.

\(f\) After absorption of a spill, the involved area will be washed
thoroughly three times using a detergent solution followed by clean
water.

\(g\) Once a cloth comes in contact with the contaminated area, it may
not be rinsed in the cleaning solution, but must be discarded in the
appropriate cytotoxic waste container.

\(h\) Any material which comes in contact with potentially contaminated
areas or materials including gloves, gown, absorbent material, and
cleaning cloths must be disposed of in a cytotoxic waste container.

g\. [Disposal of Cytotoxic Wastes in Patient Care Areas]{.underline}.

\(1\) Place all contaminated items such as syringes, needles,
chemotherapy intravenous bags, and tubing in the puncture proof fiber
drum labeled \"Cytotoxic Waste.\" Do not crush, clip, or cap needles
before disposing.

\(2\) All cytotoxic wastes, including contaminated dressing, blue pads,
and absorbent materials used to clean up spills will be disposed of in
the cytotoxic waste container.

\(3\) Linen contaminated with blood or body fluids from a patient who
has received cytotoxic drugs within the last 48 hours should be placed
in an impervious linen bag.

h\. [Disposal of Cytotoxic Wastes]{.underline}. Cytotoxic waste
containers will be collected at least once weekly or whenever the
container is more than half full. This waste will be stored in the
infectious waste trailer until picked up by a licensed disposal firm for
incineration.

i\. [Medical Surveillance]{.underline}. The medical surveillance program
for personnel preparing, administering and cleaning up spills of
cytotoxic drugs will include preplacement, periodic (determined by level
of exposure), post-exposure, and exit medical examinations. Examination
will establish a baseline and identify any subsequent disease or toxic
effect. Examinations will include:

\(1\) Personal and occupational medical history.

\(2\) Complete blood count and urinalysis.

\(3\) Physical examination with evaluation of areas vulnerable to
exposure such as eyes, skin, buccal and nasal membranes.

4\. [RESPONSIBILITY]{.underline}:

a\. Pharmacy Service will prepare all chemotherapeutic agents.

b\. Pharmacy, Patient Care, and Facilities Maintenance employees will
maintain records of employees who prepare, administer, or handle
anti-neoplastic admixtures or wastes.

c\. Drug administration and patient monitoring of these drugs is the
responsibility of registered nurses and physicians. Nurses will ensure
that extravasation kits are available in the treatment area when
administering vesicants or potential vesicants.

d\. All involved personnel are responsible for proper handling and
segregation of waste prior to disposal.

e\. Disposal of waste will be handled in accordance with the "Hazardous
Materials Management Program," Policy Memorandum 00-3.

f\. Small spills will be resolved by pharmacists and nurses. Maintenance
will be responsible for large spills.

g\. In addition to precautions described for chemotherapeutic agents in
general, investigational cytotoxic agents will be used in compliance
with Policy Memorandum 11-73, "Investigational Drug Handling."

h\. All services will educate and train personnel in matters pertaining
to cytotoxic agents.

i\. Facilities Maintenance employees will dispose of chemotherapeutic
waste to the infectious waste trailer.

j\. Employee Health will schedule and administer physicals.

k\. Industrial Hygienist serves as the Hazardous Drug Officer. He
responds to complaints and/or safety hazards as reported to him as well
as offer technical assistance.

5\. [REFERENCES]{.underline}:

U.S. Department of Health and Human Services. \"Recommendations for the
Safe Handling of Parenteral Anti-neoplastic Drugs.\" 1982

National Study Commission Cytotoxic Exposure. \"Recommendations for
Handling Cytotoxic Agents.\" September 1984

Lajeunesse, J.D., \"Precautions for Preparing Cytotoxic Agents.\"
Parenterals 1:(4), 1983

Stollar, M.H., \"Recommendations for Handling Cytotoxic Drugs in
Hospitals\"

40:(7) pg. ll63‑ll7l, 1983

VA Circular 10‑85‑97, \"Management of Anti-neoplastic Drugs.\" July 1985

Salimando, D.A., \"Preparation of Anti-neoplastic Drugs: A Review.\"
American

Journal of Intravenous Therapy and Clinical Nutrition. 10(E) pg. 16‑27,
1983

Vaccari, P.L. \"Disposal of Anti-neoplastic Wastes at National Institute
of Health.\" American Journal of Hospital Pharmacy 1 (2): pg. 87‑93,
1984

American Journal of Hospital Pharmacy. Technical Assistance Bulletin on
Handling Cytotoxic and Hazardous Drugs. American Journal of Hospital
Pharmacy 47: pg. 1033-49, 1990

OSHA Instructional CPL 2-2.20B CH-4, Chapter 21, \"Controlling
Occupational Exposure to Hazardous Drugs\", April 1995.

Nursing Policy Procedure for Chemotherapy Administration AAVAMC February
1996.

Oncology Nursing Society. Cancer Chemotherapy Guidelines and
Recommendations for Practice. Oncology Nursing Press. Second Edition,
1999.

JCAHO Manual, Environment of Care chapter

6\. [RESCISSIONS]{.underline}: Policy Memorandum 11-64, dated October 1,
1998

7\. [EXPIRATION DATE]{.underline}: July 2003

8\. [FOLLOW-UP RESPONSIBILITY]{.underline}: Pharmacy Service

*James W. Roseborough*

JAMES W. ROSEBOROUGH

Director

Attachments (2)

Distribution: E + 30 for 119