Standard Operating Procedure

(1)

Last Review Date: March 2014

Version: 1.0 Page 1 of 6

Purpose of this document

To provide a framework for all staff who work in the Community setting, who dispose of Pharmaceutical Waste during their working practise.

All bins containing pharmaceutical waste must be stored out of sight of the public in a safe and secure place.

1. Pharmaceutical Waste

1.1 Medicines used within patients home must be disposed of safely and in the correct manner. Only waste generated during the visit should be disposed of in an approved container, stored upright to prevent leakage. Patients own unwanted medicines must be returned to their local pharmacy for destruction, this includes patients own sharps containers.

1.2 Pharmaceutical waste from medicine administration must be disposed of in specialist waste bins- ‘Blue’ burn bins for Non Hazardous pharmaceutical waste and ‘Purple lidded’ burn bins for Hazardous cytotoxic waste. The bins must be stored in a cool, secure and appropriate waste store.

1.3 All pharmaceutical burn bins should be closed and sent for disposal 3 months from the date of set up. This helps control any infections or reactions that may occur within the bins. Closed bins should be stored in a safe and secure

Standard Operating Procedure

Title: Waste Management of Medicines and other Pharmaceutical Products in the Community Setting

Prepared by: Sam Durant

Presented to: Care & Clinical Policies Date: 19th March 2014 Ratified by: Care & Clinical Policies

Group

Date: 22nd March 2014

Review date: February 2016

(2)

place, not on floors or window sill where they can be potentially knocked over. The date they are sealed must be added.

1.4 All Waste must be segregated at the point of origin and secured in containers that meet the specific standards, colour and design for the particular waste category. Solid and Liquid waste must be disposed of in separate containers. All bins must be assembled correctly with the lid matching the bottom label or bin colour.

1.5 For personal protection when disposing of medicines, wear disposable gloves and apron during the process of sorting and disposing of waste. Basic personal hygiene e.g. hand washing must be carried out to reduce the risk from waste. Bins should be wiped over when leaving properties to prevent cross contamination.

1.6 Staff safety is paramount and where it is unsafe or not possible to segregate medicines before disposal and you are unsure of whether they contain cytotoxic or cytostatic products, then they must be disposed of as hazardous waste.

1.7 Do not remove medicines from their original packaging e.g. foil blisters and bottles.

2. Pharmaceutical Non-hazardous Waste (Not Cytotoxic / Cytostatic) – Blue (No Sharps)

PRODUCT ORDER CODE: 5L FSL067 11.5L FSL068 22L FSL072

2.1 Containers must be marked with black permanent marker to identify whether they contain solid or liquids and the date of assembly added. The lid must be

(3)

fitted to the container before use and the closure should be in the temporary closed position when not in use.

ALL CONTAINERS MUST HAVE:

 COMPLETED LABELS -The label should display the code 18 01 09 and 20 01 32  DATE STARTED

 PREMISES/WARD/TEAM  DATE CLOSED

When ¾ full please seal, date and dispose of as appropriate to the site. Containers will not be collected unless the labels have been completed.

3. Waste Hazardous Cytotoxic and Cytostatic - Purple

PRODUCT ORDER CODE: 1L FSL370, 2.5L FSL004, 5L FSL409

Community nursing involves contact with many items listed on the hazardous list below, and these must be disposed of correctly.

Containers must be marked with black permanent marker to identify whether they contain solid or liquids, the date of assembly added.

ALL CONTAINERS MUST HAVE:

 COMPLETED LABELS; The label should display the code

18 01 08 and 20 01 31 and sharps waste 18 01 08, 20 01 31 and 18 01 03  DATE STARTED

 PREMISES/WARD/TEAM  DATE CLOSED

The lid must be fitted to the container before use and the closure should be in the temporary closed position when not in use. Please ensure you wear gloves

(4)

and apron to ensure you are protected when disposing of waste. Ensure you wash your hands afterwards.

4. List of Cytotoxic and Cytostatic Medicines

Check combinations products as they may contain any of the listed medicines and be classified as hazardous. If you have hazardous liquids or you are unsure about any medication please contact the supplying pharmacy.

To obtain a copy of the current list of Cytotoxic and Cytostatic medicines follow the link immediately below. All departments must display a current copy of the list for staff to read and follow for the proper disposal of waste. (Hold down CNTRL and click to open link)

http://nww.sdhct.nhs.uk/EFM/directorate_office/environmental_services/waste_manag

ement/Documents/CYTOTOXIC%20LIST_amended.docx

5. Spillage Kits

The following kit has been identified as being suitable for use for cytotoxic or cytostatic spills when administering medication and can be ordered using the code MJZ015 Spill Kit.

Cytotoxic single - use pack containing: 1 x shaker ct-zorb granules

1 x scoop and scraper 1 surface wipe

1 disposal bag

1 hazard warning sticker 1 anti-splash face mask 1 protective apron

1 pair nitrile protective gloves and illustrated instructions.

The kit instruction must be followed. The kit must be replaced once used.

The used kit waste must be disposed of in a purple cyto bin.

(5)

6. Sharps Waste

Order Codes:

5L FSL310, 11.5L FSL310, 22L FSL313

Sharps that are contaminated with (that is, used in the administration of) non-cytotoxic and non-cytostatic medicines should be disposed of in these bins (Yellow).

ALL CONTAINERS MUST HAVE:

 COMPLETED LABELS; the labels should display the code 18 01 09, 18 01 03 and 20 01 32

 DATE STARTED

 PREMISES/WARD/TEAM  DATE CLOSED

Bins should be stored in a secure location away from unauthorised personnel and patients. Lids should be fitted to the container before use and the closure should be in the temporary closed position when not in use.

(Note: Orange bins must not be used for pharmaceutically contaminated sharps).

7. References

Department of Health Safe Management of Healthcare Waste Version 1 updated April 2013

Waste Management of Medicines and other Pharmaceutical Products in Community Hospitals and Community Clinics.

The Controlled Waste Regulations, updated 2012

(6)

Health and Safety at Work Act 1974

Management of Health and Safety at Work Regulations 1999

Torbay Care Trust Medicines Policy for Registered Professionals C106 Revised version 2: March 2011

NHS Devon CH 006: Controlled Drugs (CDs) Ordering, Receipt and Stock Management in Community Hospitals Version 1.0

NHS Devon SOP MP 002 Management of Pharmaceutical Waste Devon PCT Provider Services Medicines Policy V3

NATIONAL GUIDANCE FOR HEALTHCARE WASTE WATER DISCHARGES Issue date: April 2011

8. Contacts for Advice on Pharmaceutical Disposal

Medicines Management team

Email: providermmteam.t-sd@nhs.net Telephone: 01803 217393 or Email: waste.sdhct@nhs.net Telephone: 01803 656811

Monitoring tool

Standards:

Item % Exceptions

Compliance with this document by ward / unit audit 100 none

Amendment History

Issue Status Date Reason for Change Authorised

V 1.0 Final March 2014 Implementation of policy for

Pharmaceutical Waste in Community Nurse setting.

Paul Humphriss