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Policy <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 />G. 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 />2. HIPAA Compliance; <br />In compliance with HIPAA regulations which provide for confidentiality of patient health information (PHI.), <br />drugs which are labeled with .patlent-specific health information (PHI) will be discarded into <br />pharmaceutical waste containers and NOT Into regular waste. <br />3. Pharmaceutical Waste: <br />Members of the patient care team who handle medications will.treat the following as pharmaceutical <br />waste: <br />a. 1V 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 -0 trace amount <br />ofnon-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 (RCR4) guidelines (see RCRA policy) or per special instructions for controlled <br />substances or chemotherapy. (see below) <br />b. NOTE: Refer to Waste Policy (PolicyStat II]: 71853111) for waste procedures related to <br />Hazardous Medications <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 />Phannaccutical Waste. Retrieved 03/18Y2020. Official copy at hitp://sh-sgmrpolicystat.cotiVpolicy/7426022!. Copyright C Page 2 of b <br />2020 Sutler Gould Medical Foundution <br />