Case study – responding to a large hazardous spillage

Even in the best systems things occasionally go wrong, acknowledges Birgit Tans, Specialist Compounding Pharmacist, University Hospitals Leuven. When a serious incident occurred in her hospital, it prompted a review of procedures and underlined the need for everyone to be aware of the correct procedures.

“We’re working with people and people can do something wrong. So, all the procedures are there but sometimes somebody forgets something”, explains Ms Tans. Sometimes a whole series of events coincides and a serious incident occurs.  Ms Tans describes how one such event occurred at University Hospitals, Leuven in December 2023.

A prescription was received for cisplatin 190 mg in 1000ml of 0.9% sodium chloride. When the injection was prepared the assistant forgot to remove 200 ml of fluid before adding the cisplatin, so the bag was over-filled, with a final volume of 1200ml instead of 1000 ml. The pharmacist released the bag after discussion with the doctor who confirmed that the extra volume was acceptable as people receiving cisplatin require extra fluids anyway.  The infusion bag was covered with a yellow bag to protect the drug from light and then put into the protective over-package. However, the light-protecting bag was sealed together with the over-package and, in fact, the over-package bag was not sealed correctly or completely.

The preparation was required urgently on the ward and so a nurse came from the ward to collect it and carry it back to the ward. Under normal circumstances it would have been placed in a sealed box for transport to the ward.  When the nurse reached the corridor outside the pharmacy the preparation fell out of the unsealed bag and burst, resulting in spillage of 1200 ml cisplatin solution.  The nurse told the pharmacy department what had happened and then hurried back to the ward – with wet (contaminated) shoes – to take a shower and change her clothing.  Pharmacy personnel took a spill kit to clean up the spillage. Because of the large volume of the spillage, additional spill kits had to be obtained.  The spillage had occurred just before lunchtime in a busy corridor that leads to the staff restaurant so the task of preventing people from walking over the area and potentially spreading the drug further, was made more difficult. The cleaning department was asked to clean the whole area and the safety department was informed. It took almost two hours before the whole area was decontaminated, said Ms Tan.

“We learned a lot of out of this case”, she says. After the incident, some procedures were reviewed and refreshed and steps were taken to ensure that all staff were aware of the correct procedures to be followed.

Closing messages

“I would recommend people to take the European guidance document, which is unfortunately only available now in English but it will be translated to all member states’ …. languages. … I would recommend [that] people read that document and go to the table which is relevant for your profession, so you need not to read the whole document but just take the sections that are relevant, which are mostly three four five sections out of the whole document”, says Dr Sessink.  Readers should compare the recommendations with what is done in their own hospitals and consider whether improvements could be made. He emphasises the value of before and after monitoring of exposure to see if changes make a difference.

Ms Tans emphasises the value of training and education of personnel who work with hazardous drugs “so that people know what they’re doing”. They should have the right materials and the right procedures and training should be repeated and refreshed to ensure that people are up-to-date with new devices and materials. Finally, she says, “in case of a spill, stay calm”.

About Birgit Tans and Paul Sessink

Birgit Tans is a hospital pharmacist at the University Hospitals of Leuven in Belgium. For the past 30 years she has specialised in compounding of cytotoxic drugs and is an expert on safe handling of hazardous drugs.

Paul Sessink first studied chemistry and later completed a PhD on hazardous drug exposure. In 1995 he founded the company, Exposure Control to provide services related to monitoring of hazardous drugs in the working environment. The company has provided services to about 350 hospitals in the world.

 

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