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Introduction: Occupational exposure to antineoplastic drugs can lead to long-term adverse effects on workers' health. A reproducible Canadian surface monitoring program was established in 2010. The objective was to describe contamination with 11 antineoplastic drugs measured on 12 surfaces among hospitals participating in this annual monitoring program., Methods: Each hospital sampled six standardized sites in oncology pharmacies and six in outpatient clinics. Ultra-performance liquid chromatography coupled with tandem mass spectrometry was used for cyclophosphamide, docetaxel, doxorubicin, etoposide, 5-fluorouracil, gemcitabine, irinotecan, methotrexate, paclitaxel, and vinorelbine. Platinum-based drugs were analyzed by inductively coupled plasma mass spectrometry; this excludes inorganic platinum from the environment. Hospitals filled out an online questionnaire about their practices; a Kolmogorov-Smirnov test was used for some practices., Results: One hundred and twenty-four Canadian hospitals participated. Cyclophosphamide (405/1445, 28%), gemcitabine (347/1445, 24%), and platinum (71/756, 9%) were the most frequent. The 90th percentile of surface concentration was 0.01 ng/cm² for cyclophosphamide and 0.003 ng/cm² for gemcitabine. Centers that prepared 5000 or more antineoplastic per year had higher concentrations of cyclophosphamide and gemcitabine on their surfaces ( p   =  0.0001). Almost half maintained a hazardous drugs committee (46/119, 39%), but this did not influence the cyclophosphamide contamination ( p   =  0.051). Hazardous drugs training was more frequent for oncology pharmacy and nursing staff than for hygiene and sanitation staff., Conclusions: This monitoring program allowed centers to benchmark their contamination with pragmatic contamination thresholds derived from the Canadian 90th percentiles. Regular participation and local hazardous drug committee involvement provide an opportunity to review practices, identify risk areas, and refresh training., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Introduction: Occupational exposure to antineoplastic drugs can lead to long-term adverse effects on workers' health. Environmental monitoring is conducted once a year, as part of a Canadian monitoring program. The objective was to describe contamination with 11 antineoplastic drugs measured on surfaces., Methods: Six standardized sites in oncology pharmacy and six in outpatient clinic were sampled in each hospital. Samples were analyzed by ultra-performance liquid chromatography coupled with tandem mass spectrometry (non-platinum drugs) and by inductively coupled plasma mass spectrometry (platinum-based drugs). The limits of detection (in ng/cm 2 ) were: 0.0006 for cyclophosphamide; 0.001 for docetaxel; 0.04 for 5-fluorouracil; 0.0004 for gemcitabine; 0.0007 for irinotecan; 0.0009 for methotrexate; 0.004 for paclitaxel, 0.009 for vinorelbine, 0.02 for doxorubicine, 0.0037 for etoposide and 0.004 for the platinum. Sub-analyses were done with a Kolmogorov-Smirnov test., Results: 122 Canadian hospitals participated. Cyclophosphamide (451/1412, 32% of positive samples, 90 th percentile of concentration 0.0160 ng/cm 2 ) and gemcitabine (320/1412, 23%, 0.0036 ng/cm 2 ) were most frequently measured on surfaces. The surfaces most frequently contaminated with at least one drug were the front grille inside the biological safety cabinet (97/121, 80%) and the armrest of patient treatment chair (92/118, 78%).The distribution of cyclophosphamide concentration was higher for centers that prepared ≥ 5000 antineoplastic drug preparations/year (p < 0.0001)., Conclusions: This monitoring program allowed centers to benchmark their contamination with pragmatic contamination thresholds derived from the Canadian 90 th percentiles. Problematic areas need corrective measures such as decontamination. The program helps to increase the workers' awareness.

Introduction: Healthcare workers exposure to antineoplastic drugs can lead to adverse health effects. Guidelines promote the safe handling of antineoplastic drugs, but no safe exposure limit was determined. Regular surface sampling contributes to ensuring workers safety., Methods: A cross-sectional monitoring is conducted once a year with voluntary Canadian centers, since 2010. Twelve standardized sampling sites were sampled. Samples were analyzed by high performance mass coupled liquid chromatography. The limits of detection (in ng/cm 2 ) were: 0.001 for cyclophosphamide and gemcitabine; 0.3 for docetaxel and ifosfamide; 0.04 for 5-fluorouracil and paclitaxel; 0.003 for irinotecan; 0.002 for methotrexate; 0.01 for vinorelbine., Results: The surfaces from 109 centers were sampled between 01/01/2020-18/06/2020. Twenty-six centers delayed their participation because of the COVID-19 pandemic. 1217 samples were analyzed. Surfaces were frequently contaminated with cyclophosphamide (34% positive, 75th percentile 0.00165 ng/cm 2 ) and gemcitabine (16% and <0.001 ng/cm 2 ). The armrest of patient treatment chairs (84% to at least one drug), the front grille inside the biological safety cabinet (BSC) (73%) and the floor in front of the BSC (55%) were frequently contaminated. Centers that prepared ≥5000 antineoplastic drugs annually had higher concentration of cyclophosphamide on their surfaces (p < 0.0001). Contamination measured on the surfaces was reduced from 2010 to 2020., Conclusions: This large-scale study showed reproducible long term follow up of the contamination of standardized sites of Canadian centers and a reduction in surface contamination from 2010 to 2020. Periodic surface sampling help centers meet their continuous improvements goals to reduce exposure as much as possible. The COVID-19 pandemic had a limited impact on the program.

Purpose: The main objective was to determine the efficacy of various types of cleaning equipment and products after deliberate contamination with cyclophosphamide. The secondary objective was to test various cleaning scenarios using these equipment and products., Methods: The study had two phases: testing of cleaning equipment (wipe : woven microfibers - Hygen®, two layers of non-woven microfibres and an inner layer of highly absorbent viscose fibres - MicronSolo®, two layers of non-woven microfibres and an inner layer of highly absorbent viscose fibres - MicroMix®, simili-tissu (low filament production) - Tork® and, mop : woven microfibers - Hygen®, microfibre and viscose - MicroOne®) and products (disinfectant : quaternary ammonium - DR100®, chlorine 0.1% - Zochlor® - Brutab® - PCS® NPH, sodium hypochlorite 2%, cleaner : detergent - Nu- Action 3®, cleaner and disinfectant: sodium hypochlorite 0.6% + detergent - Aliflex® and water) in phase 1 and testing of various cleaning procedures in phase 2. Specific areas of a room with a laminar flow hood (class II/type B2) were contaminated with 10 mcg of cyclophosphamide. Different types of surfaces were cleaned with various scenarios and the remaining cyclophosphamide was measured by the Institut national de santé publique du Québec. All tests were performed in triplicate., Results: A total of 189 samples were obtained: 42 negative controls and positive controls, 54 during phase 1 and 93 during phase 2. All products were more than 96.5% effective. The 0.1% chlorines were the most effective products. Cleaning procedures with two or three products had average cleaning efficacies of 99.94-99.99%. Efficacy increased with the number of successive cleanings. When two products were used, the average cleaning efficacy varied between 99.78% and 99.98%, depending on the surface., Conclusion: All cleaning products tested reduced cyclophosphamide contamination by more than 96.58%. Cleaning efficacy increased with successive cleaning. No scenario was effective in removing 100% of traces. Additional studies with larger samples should be conducted to confirm these results.

Context Oncology workers are occupationally exposed to antineoplastic drugs. This exposure can induce adverse health effects. In order to reduce their exposure, contamination on surfaces should be kept as low as possible. Objectives To monitor environmental contamination with cyclophosphamide, ifosfamide, and methotrexate in oncology pharmacy and patient care areas in Canadian hospitals. To describe the impact of some factors that may limit contamination. Methods This is a descriptive study. Twelve standardized sites were sampled in each participating center (six in the pharmacy and six in patient care areas). Samples were analyzed for the presence of cyclophosphamide, ifosfamide, and methotrexate by ultra-performance liquid chromatography tandem mass spectrometry technology. Descriptive statistical analyses were done and results were compared with a Kolmogorov-Smirnov test for independent samples. Results In 2015, 48 hospitals participated in this study (48/202, 24%). Overall, 34% (181/525) of the samples were positive for cyclophosphamide, 8% (41/525) for ifosfamide, and 6% (31/525) for methotrexate. The 75th percentile value of cyclophosphamide surface concentration was 6.9 pg/cm 2 . For ifosfamide and methotrexate, they were lower than the limit of detection. Centers who prepared more antineoplastic drugs per year and centers who used more cyclophosphamide per year showed significantly higher surface contamination ( p < 0.0001). Over the years, we observed a reduction in surface contamination. Conclusion In comparison with other multicenter studies that were conducted in Canada, the concentration of antineoplastic drugs measured on surfaces is decreasing. Regular environmental monitoring is a good practice in order to maintain contamination as low as reasonably achievable.

Purpose There are health risks to workers occupationally exposed to antineoplastic drugs. We hypothesized that implementing a biological monitoring program would be feasible. The goal was to present the results of our pilot cross-sectional study of biological monitoring of four antineoplastic drugs. Methods We recruited workers from the hematology-oncology department and control workers in a mother-child university health center. This study was preceded by an information period during which we aimed at enhancing the workers' awareness and knowledge of the risks of occupational exposure. Participants filled out a journal containing activities performed and personal protective equipment worn. One urine sample was collected at the end of their shift. Samples were analyzed by UPLC/MS-MS for the presence of cyclophosphamide, ifosfamide, methotrexate, and alpha-fluoro-beta-alanine (5-fluorouracile's main urinary metabolite). Results The participation rate was 85.7% (102/119). No urine sample had detectable concentrations of any of the four drugs evaluated (0/101; 0/74 nurses, 0/11 pharmacists, 0/9 pharmacy technicians, and 0/7 doctors). In the 5 days before sampling, 67/92 (72.8%) hematology-oncology participants performed at least one activity with antineoplastic drugs. Nurses wore all of the recommended protection for technical activities (86.2%), but rarely for non-technical activities (14.9%). Pharmacists and pharmacy technicians wore all of the recommended protection for all activities (100.0%). Conclusions This pilot study had a good participation rate. The absence of positive samples was a good indication that the measures in place ensured workers' safety, even though we found areas where the worker protection can be enhanced.

Objectives: The main objective was to evaluate whether the level of agreement of oncology hospital pharmacists with statements on their impact is influenced by the presence or absence of evidence-based data. The secondary objective was to evaluate the relative importance of evidence-based data among factors that may have contributed to oncology pharmacy practice evolution., Methods: Oncology pharmacists' answered a Web questionnaire to measure their level of agreement with statements regarding their impact. Respondents answered the questionnaire before (pre) and after (post) being informed whether supporting evidence was available for each statement. Respondents were also asked to rank all of the factors in order of their perceived contribution to oncology pharmacy practice evolution., Results: A total of 64 questionnaires were obtained. Respondents reported a high level of agreement with statements regarding their impact on oncology pharmacy practice (mean agreement of 95.9% pre vs 93.8% post). A statistically significant diminution in the level of agreement was observed for 3 statements after respondents were informed that no supporting evidence was available for these statements. Respondents assigned a high importance to factors related to the perception of positive outcomes of pharmaceutical activities on patient safety, health care costs, and clinical results but a low importance to the use of evidence-based data., (© The Author(s) 2013.)

Purpose: To evaluate how nursing staff felt about the impact of automated dispensing cabinets (ADCs) on the safe delivery of health care and workplace ergonomics. To identify the main issues involved in the use of this technology and to describe the corrective measures implemented., Methods: Cross-sectional descriptive study with quantitative and qualitative components. A questionnaire that consisted of 33 statements about ADC was distributed from May 24 to June 3, 2011., Results: A total of 172 (46%) of 375 nurses completed the questionnaire. Nursing staff considered the introduction of ADC made their work easier (level of agreement of 90%), helped to safely provide patients with care (91%), and helped to reduce medication incidents/accidents (81%). Nursing staff was particularly satisfied by the narcotic drugs management with the ADCs. Nursing staff were not satisfied with the additional delays in the preparation and administration of a medication dose and the inability to prevent a medication from being administered when stopped on the medication administration record (48%)., Conclusion: The nursing staff members were satisfied with the use of ADC and believed it made their work easier, promoted safe patient care, and were perceived to reduce medication incidents/accidents.

Objectives: The aim was to compare nursing staff compliance over the years, per health care unit, and per drug use process step., Methods: Compliance assessment was performed by nursing consultants with direct observation of the registered nurses and nursing assistants during the performance of 7 steps of the drug use process. A total of 36 compliance criteria were developed. The compliance to drug use process criteria was measured in 2007 (Prephase), 2008 (post 1), and 2011 (post 2). Totally, 10 health care units were evaluated, with a minimum of 10 doses evaluated per health care unit, including a minimum of 5 parental doses and a total of 100 nurses observed., Results: A total of 142 nurses were observed in the prephase, 140 nurses in the post 1 phase, and 98 in the post 2 phase (90% regular staff and 10% float staff). The overall compliance rates went from 77% in 2007 up to 87% in 2008 and down to 78% in 2011., Conclusions: This cross-sectional observational study revealed a significant difference in the drug use process compliance in terms of drug preparation and drug administration for inpatients at the bedside, between 2007 and 2011.

Objectives: The primary objective was to examine the consistency of prioritization decisions made by pharmacy residents in a simulated environment where the available resources are constrained. Secondary objectives were to rank the factors that influenced their prioritization and to compare the residents' results with those of Canadian pharmacy leaders., Methods: We have developed a prioritization exercise that aims at evaluating how pharmaceutical activities are prioritized. The simulation was conducted with hospital pharmacy residents in 2 Quebec universities in 2011., Results: Residents covered a similar number of activities in the prioritization simulation (mean 27 of 32). Teams tended to favor a broad range of services delivered less comprehensively. Participants ranked "perception of the favorable impact of the activity on health outcomes" higher than "conclusive evidence available to support the decisions." The relative weight attributed per domain was similar between pharmacy residents and pharmacy leaders, but their ranking of factors that influenced their decisions was different., Conclusions: Pharmacy residents opted to provide a wide range of services, but at a low level of comprehensiveness. The high variation between each team's coverage per activity in this simulation supports the observation that pharmacy residents do not agree on a core set of pharmaceutical activities that should be prioritized.

Objectives: In our Quebec (Canada) University Hospital Center, 68 medication carts have been implemented as part of a nationally funded project on drug distribution technologies. There are limited data published about the impact of medication carts in point-of-care units. Our main objective was to assess nursing staff's perception and satisfaction of medication carts on patient safety and ergonomics., Method: Quantitative and qualitative cross-sectional study. Data were gathered from a printed questionnaire administered to nurses and an organized focus group composed of nurses and pharmacists., Results: A total of 195 nurses completed the questionnaire. Eighty percent of the nurses agreed that medication carts made health care staff's work easier and 64% agreed that it helped to reduce medication incidents/accidents. Only 27% and 43% agreed that carts' location reduces the risk of patients' interruptions and colleagues' interruptions, respectively. A total of 17 suggestions were extracted from the focus group (n = 7 nurses; n = 3 pharmacist) and will be implemented in the next year., Conclusions: This descriptive study confirms the positive perception and satisfaction of nurses exposed to medication carts. However, interruptions are a major concern and source of dissatisfaction. The focus group has revealed many issues which will be improved.

Objective: To describe environmental contamination with hazardous drugs in a hospital pharmacy setting before and after reorganizing a hematology- oncology satellite pharmacy., Methods: This is a descriptive study of surface contamination with cyclophosphamide, ifosfamide, and methotrexate in two hematology-oncology satellite pharmacies. In order to measure surface contamination with hazardous drugs, samples from four distinct measurement sites within the pharmacy were taken in each of the two phases (pre-and postphases) using a sampling procedure and an analytical method modified from Larson et al., Results: A total of 133 samples from four measurement sites were taken and analyzed over the course of the study (specifically 60 prephase samples and 73 postphase samples). The study showed a significant increase in the number of positive samples (from 66.7% to 90.4%, p<0.001) from the pre- to the postphase. The increase, however, is only significant in terms of the location where completed preparations were placed after they had come out from under the hood (from 0/15 to 21/28, p<0.001) and the work surface (from 8/15 to 15/15, p=0.006) and only in terms of ifosfamide. Furthermore, for the other sites studied, the number of positive samples remained unchanged between the pre- and postphase. A statistically significant difference between the pre- and postphase was observed in terms of ifosfamide for three of the four measurement sites studied and methotrexate for one of the four sites. Average concentrations were higher in the post phase in three of the four cases., Conclusion: This study describes environmental contamination with hazardous drugs in a hospital pharmacy setting before and after reorganizing a hematology-oncology satellite pharmacy. The study showed that a refitting of the hemato-oncology pharmacy is not a sufficient strategy to reduce the environmental contamination by ifosfamide because a significant increase in the number of positive samples from the pre- to the postphase have been observed. Many factors can contribute to influence the contamination of hazardous drugs such as the workflow and the training of the personal. Continuous environmental surveillance of hazardous drugs is required to document traces and help reduce risks.