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Dignity Health_ <br />5t. Joseph's Medical Center <br />Page 1 of 11 <br />Title: <br />Pharmaceutical Waste Program <br />Policy No: <br />MM.05.01.19.01 <br />Date of Origin: <br />01/04 <br />Department/System: <br />Medication Management <br />Reviewed: 01/07,11/08 <br />Revised: 03/04, 3/10, 2/14 <br />1. 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 />IL 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. 6909 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B. Unusable Pharmaceuticals - outdated or otherwise unusable drugs <br />1. Chemotherapy wastes: Trace Chemotherapy wastes - A container is <br />considered trace chemotherapy waste if: <br />2. All the chemotherapy drug has been removed using practices commonly <br />employed 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 drug vial <br />C. Bulk Chemotherapy wastes — Chemotherapy drug that is of a sufficient quantity <br />that can be poured or will flow out of the container. Examples are partially used or <br />unused vial or syringe with chemotherapy unit, unused intravenous solution, unused <br />or expired product that can not be returned to the provider and waste generated by <br />cleaning up 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 />