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l_V_ Dignity Health. <br /> 1/Y St.Joseph's Medical Center <br /> Page lofll <br /> Title: Policy No: Date of Origin: <br /> Pharmaceutical Waste Program MM.05.01.19.01 01/04 <br /> Department/System: Reviewed: 01/07, 11/08 <br /> Medication Management Revised: 03/04, 3/10, 2/14, 12/16 <br /> I. PURPOSE <br /> To establish a management plan, policies and procedures to ensure that <br /> pharmaceutical wastes generated at the medical center are handled, stored, transferred <br /> and disposed of in a manner that is occupationally safe, environmentally responsible <br /> and meets applicable legal requirements. <br /> II. DEFINITIONS <br /> A. Pharmaceutical means any prescription or over-the-counter medications. <br /> Pharmaceutical does not include any pharmaceutical that is regulated pursuant to <br /> either of the following: <br /> 1. Federal Resource Conservation and Recovery Act of 1976 as amended (42 <br /> U.S.C.A. Sec. 6901 ET seq.) <br /> 2. Radiation Control Law Chapter 8 (Section 114960 of Part 9). The Radiation <br /> Safety Officer manages radioactive isotopes. <br /> B. Unusable Pharmaceuticals — Medications outdated (i.e. expired) or otherwise <br /> deemed tampered with <br /> 1. Chemotherapy wastes: Trace Chemotherapy wastes - A container is <br /> considered trace chemotherapy waste if: <br /> 2. All chemotherapy drug has been removed using practices commonly employed <br /> to remove materials from that type of container. <br /> 3. No more than 3% by weight of the total capacity of the container remains in the <br /> container <br /> 4. Examples of trace chemotherapy waste are: <br /> a. Contaminated gowns, gloves, masks, cleaning clothes, and barriers <br /> b. Empty IV tubing <br /> c. Empty IV bags/bottles <br /> d. Empty syringes <br /> e. Empty chemotherapy vial <br /> C. Bulk Chemotherapy wastes — Chemotherapy that is of a sufficient quantity that can <br /> be poured or will flow out of the container (i.e. partially used or unused vial or <br /> syringe with chemotherapy unit, unused intravenous solution, unused or expired <br /> product that can not be returned to the provider and waste generated by cleaning up <br /> a spill). <br /> D. Sharps Waste - Any discarded device that was used in patient care, or laboratory <br /> and is capable of puncturing or cutting the skin. Examples included needles, <br /> syringes with needles attached; trocars; pipettes; blades; broken glass vials. <br />