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Hazardous Medication PPE Guide

February 12 , 2018

Forwarded on behalf of Tara Dumont, Manager, Medication Management 

About this implementation FAQ 

The Hazardous Medication PPE Guide for Alberta Health Services and Covenant Health was approved on December 13, 2017.

The guide gives direction on the safe handling of hazardous medications to reduce staff exposures to these in the workplace.

On January 10, 2018, the Hazardous Medication PPE Guide and required resources were posted on CompassionNet and the Covenant Health Medical Staff Portal.

This implementation FAQ is meant for Managers, Clinical Nurse Educators and other individuals in management roles. It summarizes a variety of answers to questions that management may receive from staff regarding the implementation of the Hazardous Medication PPE Guide. It is meant to provide context in terms of how and why the Hazardous Medication PPE Guide was developed. This implementation FAQ is not meant to replace the other Hazardous Medication documents for all staff that are presently on the Covenant Health Medical Staff Portal.

Background Information 

1. Why was the Hazardous Medication PPE Guide and list of hazardous medication developed?

Alberta Occupational Health and Safety legislation requires that employers put control measures in place to ensure safety of workers when handling hazardous medications. The guide was developed to ensure staff are wearing the appropriates PPE when handling hazardous medications to minimize the risk of occupational exposure.

2. How do we know the Hazardous Medication PPE Guide and list will make staff safer?

The information in the guide is taken from the National Institute of Occupational Safety and Health (NIOSH) and the United States Pharmacoepoia (USP). Information from the National Association of Pharmacy Regulatory Authorities (NAPRA) was also used for development. Please refer to the guide for a comprehensive list of references.

3. Who developed the Hazardous Medication PPE Guide?

The guide was developed by the Hazardous Medication Evaluation Committee (HazMEC), a subgroup of the interdisciplinary Provincial Medication Management Committee (PMMC). HazMEC members include representatives from AHS Workplace Health & Safety, Pharmacy Services, Health Professions Strategy and Practice, CancerControl, Continuing Care, Covenant Health, Corrections and Nursing Leaders. Ad Hoc Members include Lab Services, Linen and Environmental Services and Emergency Medical Services.

4. Who was consulted?

HazMEC, PMMC, Covenant Health Medication Management Steering Committee, Senior Leadership Team and Operational Leadership team within Covenant Health were all consulted.

Consultation also included the following:

  • Members of HazMEC connecting with their peer groups to gather stakeholder feedback.
  • Human Factors usability testing was conducted with the following staffing groups - Nursing, Pharmacy, Physicians, EMS, Respiratory Therapy, CPSM and Portering.

Organizational Impact

1. Why did I not hear of this before it was implemented? Why was I not given notice through a "soft-launch"?

The original intent was to have a soft-launch that would prepare staff for these changes similar to other provincial initiatives. In this instance, AHS Health Law advised the HazMEC Provinicial team to proceed with immediate release of the materials acknowledging it would take time for full implementations to occur.

2. Are there specific deadlines for implementing the guide? 

Covenant Health is currently conducting a stakeholder review through organization working groups and Pharmacy focus groups to understand the impacts of the guide to our teams. Following the conclusion of thse working froups, education materials and a roll out plan will be made available to teams. We recognize some areas may require more extensive change management and education than others. All areas are expected to identify and address areas of concern as soon as possible.

The implementation of the guide in Covenant Health will be complete when all safety strategies are in place. These safety strategies include: messages on the medication administration records indication medication are hazardous, labels on medication indicating they are hazardous, communication around storage and labelling requirements, patient room signage, staff education, Personal Protective Equipment available on units for staff to utilize, waste containers available for staff to dispose of waste correctly, and clinical concerns about process and practice change have been addressed.

3. Are there education resources available?

Managers and Clincal Nurse Educators are expected to use the resources posted on the Hazardous & Cytotoxic Medication webpage.

Once the education PowerPoint is finalized it will be made available in CLiC for staff use. The final CLiC module will be accompanied with comprehension test questions to assess understanding and consolidate learning.

Requests for consultation related to nursing practice can be submitted through the Professional Practice consultation service on the Medical Staff Portal. Please click here.

In the coming weeks, there will also be Skype sessions organized for managers and Clincal Nurse Educators.

4. Was cost considered when this guide and list was approved? 

Yes, cost projections were discussed with senior leadership. Additional concerns related to costs should be directed to your management team.

5. Will Pharmacy now prepare hazardous medication that nursing previously were responsible for?

No, there is no expectation that Pharmacy is now responsible for preparing all hazardous medications. Activities currently performed by nursing will continue to be performed by nurses with appropriate PPE.


1. What process should be followed for documenting workers with concerns about historical exposure? 

If staff are concerned regarding potential past exposure they should report the concern to their manager and Covenant Health Occupation Health, Safety & Wellness (OSH&W) Workplace Incident Reporting  Line at 780.342.3070 or toll free at 1.855.342.8070. As required, OSH&W will provide direction regarding WCB submission as a notification.

2. Where do questions about the guide get directed to? 

For questions related to occupational health and safety and occupation exposure contact OHS&W Team at

For questions related to safe handling of hazardous medications, please contact Medication Management at or your local Pharmacy department.  


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