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• 0 <br />1. Responsibility: <br />a. Management of pharmaceutical waste is a collaborative team effort where all staff participates to <br />ensure compliance with law. <br />b. Responsibilities for pharmaceutical waste management at this facility are shared among the <br />Engineering Manager, Infection Control Nurse, and Department Managers of patient care areas. <br />c. Disposal of all pharmaceutical waste is handled by the direct patient care providers and <br />environmental service personnel who have been trained in its proper disposal. Waste will be <br />inspected at the time of disposal by every person who discards trash to assure proper disposal. <br />d. All employees and staff are responsible to instruct and monitor the pharmaceutical waste disposal <br />practices of physician, students, and contract employees. <br />HIPAA Compliance: <br />In compliance with HIPAA regulations which provide for confidentiality of patient health information (PHI), <br />drugs which are labeled with patient -specific health information (PHI) will be discarded into <br />pharmaceutical waste containers and NOT into regular waste. <br />Pharmaceutical Waste: <br />Members of the patient care team who handle medications will treat the following as pharmaceutical <br />waste: <br />a. IV additives in concentrated form contained in used or; partially used syringes, multi -dose vials that <br />have the cap removed or stopper pierced, and open ampules containing more than a.trace amount <br />'of non -chemotherapy drug <br />b. IV bags or bottles containing more that a trace amount of active non -chemotherapy drug(s) in <br />solution including, but not limited to, antibiotics, painkillers, controlled substances, or vasopressor <br />agents . <br />c. Over-the-counter or prescription non -chemotherapy capsules, tablets, lozenges, powders, and <br />liquids for oral use; <br />d. Any empty drug containers or packaging labeled with patient -specific healthcare information (PHI); <br />e. Solutions for inhalation or nebulization; Suppositories, douches, rectal foams, and enemas; <br />ophthalmic, otic, and nasal preparations; Creams, ointments, gels, lotions, powders, shampoos, <br />foams, and patches containing a pharmaceutical for topical use; and Radiologic contrast media, <br />except that containing barium. <br />a. Alert: Some pharmaceutical waste must be disposed of per Resource Conservation and <br />Recovery Act (RCRA) guidelines (see RCRA policy) or per special instructions for controlled <br />substances or chemotherapy. (see below) <br />4. Segregation: <br />Each department generating pharmaceutical waste will segregate this waste stream from other waste <br />products. <br />a. Segregation of pharmaceutical waste will begin at the time and at the location that the item becomes <br />"waste". <br />b. Pharmaceutical waste will be placed into a Department of Transportation approved, rigid (sharps <br />Pharmaceutical Waste. Retrieved 03/18/2019. Official copy at http://sh-sgmfpolicystat.com/policy/5319185/. Copyright © Page 2 of 5 <br />2019 Sutter Gould Medical Foundation <br />