Part 3, Chapter 27: Manual Exhibit 3-27-E

Medical surveillance - The systematic assessment of employees exposed or potentially exposed to occupational hazards. This assessment monitors individuals for adverse health effects and determines the effectiveness of exposure prevention strategies.

1. Medical Evaluation.   The medical evaluation contains the following components.
   1. Detailed Work History.   Previous and current work experience will be reviewed including a review of quantity and dosage form of hazardous drugs handled, number handled per week, number of hours spent handling hazardous drugs per week. The work history should focus on symptoms relating to the target organs and systems associated with exposure to hazardous drugs (hematopoietic, renal/urinary, hepatic, and reproductive). Workers should be queried regarding reproductive history. Refer to Oncology Nursing Society Safe Handling of Hazardous Drugs for a sample medical surveillance form.
   2. Physical Examination.   A baseline physical exam may be used to document pre-existing findings. Periodic examinations should include skin and mucous membranes to assess for signs of rash, irritation or other evidence of exposure. Evaluations of other target organ systems may also be useful.
   3. Laboratory Testing.   A complete blood count with differential and a reticulocyte count should be taken. A complete blood cell count may be helpful as an indicator of bone marrow reserve. Urine should be monitored (either by a urine dipstick or microscopic examination of the urine for blood) as several antineoplastic agents can cause bladder damage. Liver transaminases and alkaline phosphatase tests may be useful to monitor hepatic function.
   4. Special Biological Monitoring.   For follow-up of acute spills with a specific drug, biological monitoring using blood or urine levels of the specific drug may be useful.
2. Frequency.   Employees who handle hazardous drugs must receive a medical evaluation prior to handling any hazardous drugs (serves as a baseline), after an exposure to a hazardous drug, periodically (as defined by local policy), and post-employment.
3. Reproductive Issues.   Adherence to the medical surveillance engineering controls, administrative controls, and personal protective equipment recommendations in this chapter should minimize potential hazardous drug exposures. Staff who are pregnant, attempting pregnancy (male and female), or who are nursing, may provide written voluntary disclosure to their supervisor. Supervisors should reassign these staff so that their job duties do not include the direct handling and manipulation of hazardous drugs.
4. Results.   A follow-up plan should be developed for employees who have had an acute exposure or exhibit signs of suggesting toxicity or who have experienced an acute exposure. The plan should evaluate current workflow and processes to identify necessary changes or re-education.
5. Follow-Up.   Immediate review of primary prevention measures and assessment of the controls already in use need to occur. This assessment may include the pharmacy supervisor, safety officer, Institutional Environmental Health Officers, or nurse manager. Refer to United States Pharmacopeia <800> for a complete list of actions that need to be taken.