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11 <br />Dignity Health. <br />St. Joseph's Medical Center <br />Page 3 of I I <br />B. Sharps Waste: All needles and empty syringes, scalpels, broken glass bottles, etc., <br />must be placed into the opening of rigid puncture resistant sharps container with the <br />appropriate label. <br />C. Controlled Substances Waste: <br />♦ Controlled substances not in original sealed containers <br />♦ Controlled substances in broken or damaged containers or with damaged or <br />altered labels <br />♦ Partials (less than a complete unit of issue) <br />♦ Good -dated, out -dated and short -dated Schedule [I's <br />1. The above controlled substances should be held for shipment to a <br />Pharmaceutical Waste Management Company during a scheduled controlled <br />substance destruction period. Follow Controlled Substance Destruction Policies <br />and Procedures. <br />a. All Schedule 11 substances must be written up on a DEA 222 Form. <br />b. All Schedules III through V substances must be written up on an EXP form. <br />c. If the source of the controlled substances waste is unclaimed prescriptions of <br />admitted patients, all the controlled substances must be written up by EXP on <br />a DEA222 form separating the patient medications from pharmacy stock. <br />D. Chemotherapy Wastes: <br />1. Trace Chemotherapy Waste <br />a. All trace chemotherapy waste should be deposited in yellow containers <br />labeled "Chemotherapy Waste" and "Incineration Only" visible in all <br />directions. <br />b. When the container is full, without compacting, the locking lid is to be secured <br />to prevent loss of contents prior to disposal (gowns, gloves, and other trace <br />chemotherapy contaminated non -sharps objects may also be deposited in the <br />container.) <br />c. EVS should be notified to pick up trace chemotherapy waste and to deliver it <br />to the Medical Waste Storage area to be disposed of by a licensed medical <br />waste company. <br />2. Bulk Chemotherapy (Hazardous Waste) <br />a. Bulk chemotherapy waste should be handled as hazardous waste. <br />b. Within the Biological Safety Cabinet place the bulk chemotherapy waste in a <br />zip -lock bag. <br />