Call E, Bill B, McLean C, Call N, Bernkopf A, Oberg C. Hazardous drug contamination of drug preparation devices and staff: a contamination study simulating the use of chemotherapy drugs in a clinical setting. Hosp Pharm. 2017; 52:(8)551-558

Connor TH, DeBord DG, Pretty JR Evaluation of antineoplastic drug exposure of health care workers at three university-based US cancer centers. J Occup Environ Med. 2010; 52:(10)1019-1027

Gurusamy KS, Best LMJ, Tanguay C, Lennan E, Korva M, Bussières JF. Closed-system drug-transfer devices plus safe handling of hazardous drugs versus safe handling alone for reducing exposure to infusional hazardous drugs in healthcare staff. Cochrane Database Syst Rev. 2018; 3

Gurusamy KS, Ruotsalainen J, Verbeek J Validity of criticism of Cochrane Review on closed-system drug-transfer devices. Am J Health Syst Pharm. 2019; 76:(17)1267-1269

Hon CY, Teschke K, Shen H, Demers PA, Venners S. Antineoplastic drug contamination in the urine of Canadian healthcare workers. Int Arch Occup Environ Health. 2015; 88:(7)933-941–1

ISOPP standards of practice. Safe handling of cytotoxics. J Oncol Pharm Pract. 2007; 1-81

Kibby T. A review of surface wipe sampling compared to biologic monitoring for occupational exposure to antineoplastic drugs. J Occup Environ Hyg. 2017; 14:(3)159-174

Lennan E. Considering closed-system transfer devices for safe handling of drugs. Br J Nurs. 2017; 26:(10)S26-S28

Mason HJ, Blair S, Sams C Exposure to antineoplastic drugs in two UK hospital pharmacy units. Ann Occup Hyg. 2005; 49:(7)603-610

Mathias PI, MacKenzie BA, Toennis CA, Connor TH. Survey of guidelines and current practices for safe handling of antineoplastic and other hazardous drugs used in 24 countries. J Oncol Pharm Pract. 2019; 25:(1)148-162

McDiarmid MA, Oliver MS, Roth TS, Rogers B, Escalante C. Chromosome 5 and 7 abnormalities in oncology personnel handling anticancer drugs. J Occup Environ Med. 2010; 52:(10)1028-1034

McDiarmid MA, Polovich M, Power LA, Connor TH, Kienle PC. Published review of closed-system drug-transfer devices: limitations and implications. Am J Health Syst Pharm. 2018; 75:(24)1982-1985

McDiarmid MA, Polovich M, Power LA, Connor TH, Kienle PC. Criticisms of Cochrane Review on closed-system transfer devices remain valid. Am J Health Syst Pharm. 2019; 76:(17)1269-1271

National Institute for Occupational Safety and Health. NIOSH alert. Preventing occupational exposures to antineoplastic and other hazardous drugs in health care settings. Centers for Disease Control and Prevention. (accessed 13 May 2020)

Ndaw S, Denis F, Marsan P, d'Almeida A, Robert A. Biological monitoring of occupational exposure to 5-fluorouracil: urinary α-fluoro-β-alanine assay by high performance liquid chromatography tandem mass spectrometry in health care personnel. J Chromatogr B Analyt Technol Biomed Life Sci. 2010; 878:(27)2630-2634

Soignants et médicaments cytotoxiques. Place de la biométrologie dans la maîtrise des risques dans le temps. 2018. (accessed 13 May 2020)

Ramphal R, Bains T, Vaillancourt R, Osmond MH, Barrowman N. Occupational exposure to cyclophosphamide in nurses at a single center. J Occup Environ Med. 2014; 56:(3)304-312

Roussel C, Witt KL, Shaw PB, Connor TH. Meta-analysis of chromosomal aberrations as a biomarker of exposure in healthcare workers occupationally exposed to antineoplastic drugs. Mutat Res Rev Mutat Res. 2019; 781:207-217

Guidance on handling of injectable cytotoxic drugs in clinical areas in NHS hospitals in the UK. 2018. (accessed 13 May 2020)

Sugiura S, Asano M, Kinoshita K, Tanimura M, Nabeshima T. Risks to health professionals from hazardous drugs in Japan: A pilot study of environmental and biological monitoring of occupational exposure to cyclophosphamide. J Oncol Pharm Pract. 2011a; 17:(1)14-19

Sugiura S, Nakanishi H, Asano M Multicenter study for environmental and biological monitoring of occupational exposure to cyclophosphamide in Japan. J Oncol Pharm Pract. 2011b; 17:(1)20-28

US Pharmacopeia. Compounding standards: General chapter <800> Hazardous Drugs—Handling in Healthcare Settings. 2019. (accessed 13 May 2020)

Ziegler E, Mason HJ, Baxter PJ. Occupational exposure to cytotoxic drugs in two UK oncology wards. Occup Environ Med. 2002; 59:(9)608-612

Use of a closed-system drug transfer device reduces contamination with doxorubicin during bolus injection

28 May 2020
13 min read
Volume 29 · Issue 10



Administration of doxorubicin via bolus injection may result in environmental contamination and a risk of nurses becoming exposed. Small spills are frequently observed by nurses when syringes are connected to, and disconnected from, infusion lines.


The effect of a closed-system drug transfer device (CSTD) on the release of doxorubicin was studied during administration via bolus injections.


10 administrations with the currently used technique and 10 administrations using the CSTD were compared by analysis of doxorubicin contamination on gauze pads, tissues and gloves.


Using the current technique, contamination was found during nine administrations, which was mainly on the gauze pads and, to a lesser extent, on the tissues and gloves, indicating release of doxorubicin during administration. With use of the CSTD, contamination was found only on one pair of gloves.


Use of a CSTD significantly decreased the number of spills and level of contamination compared with the currently used technique and, consequently, the use of such devices offers a safer working environment for nurses.

It has been known for many years that cytotoxic drugs may cause adverse health effects in healthcare workers involved in the preparation and administration of these substances (National Institute for Occupational Safety and Health, 2004). Extensive safety precautions are therefore taken to prevent healthcare workers from being exposed to these substances (International Society of Oncology Pharmacy Practitioners Standards Committee, 2007; Mathias et al, 2019). They include administrative measures such as guidelines, protocols, education and training, and technical measures such as clean-room facilities, biological safety cabinets, isolators and closed-system drug transfer devices (CSTDs). In addition to these measures, personal protective equipment (PPE) is used to optimise workers' safety.

Despite all these precautions and measures, there is still a potential risk for staff to be exposed to cytotoxic drugs. Studies continue to show exposure of healthcare workers by analysis of cytotoxic drugs or their metabolites in urine (Connor et al, 2010; Ndaw et al, 2010; Sugiura et al, 2011a; Sugiura et al, 2011b; Ramphal et al, 2014; Hon et al, 2015; Kibby, 2017; Ndaw et al, 2018), and genetic damage is observed in peripheral blood lymphocytes (McDiarmid et al, 2010; Roussel et al, 2019). In addition, surface wipe sampling shows environmental contamination with cytotoxic drugs in many pharmacies, and inpatient and outpatient departments, where the drugs are prepared and administered to patients (Kibby, 2017).

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