Even after decades of safety advances, hazardous drug exposure remains a daily risk for oncology nurses. According to Kelsey Miller, MSN, RN, a clinical nurse specialist in oncology and infusion therapy from Reading Hospital, Tower Health, vigilance around safe handling is as critical as ever, and far from simple.
At the 2025 Oncology Nursing Society (ONS) Bridge Conference, Ms Miller emphasized that safe handling is an evolving, multistep process that depends on consistent collaboration among everyone involved in cancer care.
Evolving Standards and Persistent Risks
She started by tracing the evolution of national standards, from the first ONS resolution on chemotherapy safety in 1983 to the 2024 update of the National Institute for Occupational Safety and Health (NIOSH) hazardous drug list. This update added 25 drugs and removed 7, collapsing the previous 3 tables into 2:
- Table 1: known or probable human carcinogens
- Table 2: not a known or probable human carcinogen but exhibits 1 or more of the types of toxicities that make up a hazardous drug
The list, she said, “is not all-inclusive” (as new drugs have come out since the latest version), and should serve as a framework for institutions to operationalize risk strategies. At Reading Hospital, every drug is labeled as NIOSH 1 or NIOSH 2, with full personal protective equipment (PPE) used for NIOSH 1 and chemo-rated nitrile exam gloves for NIOSH 2.
Under USP 800, hospitals must maintain an updated hazardous drug list and define containment or work practice controls based on drug properties. Even oral tablets can pose a risk if crushed at the bedside. “There is never a benefit of occupational exposure,” Ms Miller emphasized. “No safe level exists.”
She encourages oncology nurses to understand how these standards intersect with daily workflows—from storage and preparation to patient care—and to make safety practices visible and repeatable. “The more standardized our process, the less room there is for variation and exposure,” she noted.
Surface Contamination: The Unseen Exposure
Research shows contamination remains common. In one study, cyclophosphamide and etoposide residues were found on more than half of tested surfaces; another study showed that 55% of healthcare workers’ urine samples contained cyclophosphamide. Even unit clerks, who do not handle chemotherapy, showed measurable exposure.
“So who’s at risk?” she asked. “We all are: nurses, nurses’ aides, pharmacists, pharmacy techs, and all of our nonclinical staff that are in these rooms touching these high-touch surfaces. It truly takes a village to reduce surface contamination.”
To illustrate the invisible nature of risk, Ms Miller said, “If you think of drugs like bugs, you can imagine how easily they spread.” Contamination can occur from indirect contact, such as lowering a bed or touching an IV pole, long after a drug has been administered.
Reading Hospital’s approach includes double-gloving, defined cleaning roles for nursing and environmental services, and built-in electronic medical record and pharmacy flags identifying hazardous drugs. Internal signage alerts staff without compromising patient privacy, while consistent education reinforces why these precautions matter.
Protecting the Reproductive Workforce
Citing the ONS/Hematology/Oncology Pharmacy Association Joint Position Statement and USP 800, Ms Miller said staff of reproductive potential must be informed in writing about handling risks. However, reproductive risk remains an area of inconsistency, and reproductive safety policies vary widely across institutions.
At Reading Hospital, she helped develop a standardized acknowledgment-of-risk statement and a formal work accommodation process in compliance with the Americans with Disabilities Act. “For years, we were doing this informally,” she said. “Now it’s standardized and tracked through HR [human resources].”
These formal protections help ensure that nurses and pharmacy staff who are pregnant, breastfeeding, or trying to conceive are not placed in unsafe roles like administering antineoplastics or handling bodily fluids. This is an essential step toward a culture of transparency and support, she added.
Applying Standards in Practice
Across the continuum—from drug receipt to administration and waste disposal—adherence to PPE protocols is essential. Nurses administering hazardous drugs wear double gloves, polyethylene-coated gowns, and face protection when splash risk exists. Gowns are single-use only, and closed-system transfer devices (CSTDs) are required for administration when dosage form allows. However, she warned that technical user error and mechanical defect remain common causes of spills with CSTDs.
Ms Miller also emphasized that as cancer care increasingly extends into the ambulatory and home settings, nurses must ensure patients and families understand how to safely manage hazardous drugs and bodily fluids, using the teach-back method to confirm comprehension.
Beyond the Infusion Chair
Contamination doesn’t end when the infusion stops. Ms Miller described how chemotherapy residues can persist in bathrooms even after discharge cleaning. Reading Hospital uses plastic-backed pads over toilets during flushing and advises double-gloving and face shields when handling excreta within 48 hours of treatment (longer for certain drugs). Staff are reminded to avoid taking contaminated shoes home or to places like schools or daycares to pick up their children—an often-overlooked risk.
Such details, she said, may seem minor but reflect the broader goal: reducing cumulative exposure across every touchpoint.
Responding to Spills and Building a Culture of Safety
Small spills are handled by trained oncology nurses wearing N95 respirators; larger ones activate the hospital’s hazardous materials response team with specialized OSHA training and routine wipe sampling guides improvement, she explained.
According to Ms Miller, sustaining a culture of safety requires “unit safe handling champions,” mock drills, and regular peer-led refreshers. She emphasized that as patients and families take on more at-home responsibilities, nurses remain central to protecting safety through education, consistency, and shared accountability across the care team.