The article presented below, “Medicines under the COSHH - seven things you can do to handle medicines safely” was originally published as a module in Veterinary Prescriber’s Virtual Veterinary Medicines Academy, It is an example of how Veterinary Prescriber presents evidence-based medicines information for practical use in the veterinary practice. It is common for practices to struggle with making medicines risk assessments. This article explains how to bridge the health and safety language in COSHH regulations with accessible information about the medicines that are used in your practice. It will enable you to determine the specific actions needed to protect your own practice staff. There are helpful case studies at the end of the article.
Medicines under the CoSHH
Seven things you can do to handle medicines safely
The medicines used in veterinary practice every day can be harmful to the people who handle them. Often the level of risk from a medicine is low, but some can have devastating effects if mishandled. The consequences of mishandling can potentially include serious allergic reactions, reproductive threats and enduring effects on health.
Understanding the hazards and preventing harm is a key responsibility for a veterinary practice. The legal requirements are laid out in the Control of Substances Hazardous to Health (CoSHH) regulations and are part of the RCVS Practice Standards Scheme.
Whether you have a fully embedded CoSHH system, or are just starting to think about the risks from handling medicines, these seven steps can help you protect staff and clients from medicines hazards.
1: Make a list
All good organising starts with a list. Gather an inventory of the different medicines that the practice stocks, and any that are ordered occasionally. Your list is a starting point for researching which medicines can cause harm. You may be able to download a list from your practice computer, or from your ordering system. Then look in cupboards, vets’ cars and dark corners for other medicines that may have escaped notice. Anything in a bottle, blister pack or box can go on the list – even commonly-used medicines can be harmful if mishandled so leave nothing out.
2: Look at product information sheets
The best way to understand the potential for harm is to look at product information sheets (often known as datasheets).
For licensed veterinary medicines, the risks are outlined in the product’s Summary of Product Characteristics (SPC), in section 4.5 “Special precautions to be taken by the person administering the veterinary medicinal product to animals”. The SPC of every licensed veterinary medicine in the UK is in the VMD’s product information database. You can also find the information for most available licensed veterinary medicines in NOAH datasheets.
Human licensed medicines also contain handling advice in the SPC, along with specific advice on disposal and pregnancy and lactation. These can be used as an indication of the potential consequences of inadvertent human exposure even when the product has been prescribed for an animal. The SPC for most human medicines can be found in the electronic Medicines Compendium (eMC) and for all licensed products on the website of the Medicines and Healthcare Products Regulatory Agency (MHRA).
Unlicensed medicines have not been assessed by a medicines regulator and so will not have an SPC. Unlicensed medicines include special formulations (‘specials’), any formulation made by a vet or pharmacist and any licensed formulation that has been altered (e.g. diluted; crushed). A specials manufacturer may supply basic handling advice but you may need to search for information from formularies or other published literature. If the unlicensed formulation contains a drug that is in a licensed medicine, it may be possible to extrapolate the information from the licensed product’s SPC.
If it becomes necessary to look at other types of datasheet, look for warning phrases that indicate a potential for harm, like those in the list below.
Warning phrases to watch for
Harmful by inhalation/ contact with skin/ swallowed
Cause of burns
Irritating to eyes, skin or respiratory system
May cause sensitisation
Repeated exposure may cause skin dryness or cracking
Vapours may cause drowsiness and dizziness
Danger of cumulative effects
Possible risk of irreversible effects
May cause cancer
May cause heritable genetic damage
Danger of serious damage to health by prolonged exposure
May impair fertility, or cause harm to unborn child
3. Understand who will use the medicine, and how
In a veterinary practice, the tasks involving medicines include dispensing, administering, cleaning-up, disposal and occasionally reformulating. In these tasks, the potential routes of exposure may include skin, eye or mucous membrane contact, needlestick injury, inhalation or ingestion. Ask yourself how these tasks might increase the potential for harm to a person.
The potential for harm may be increased by altering the way the medicine is formulated or packaged; some medicines may be harmless in tablet form, but hazardous if crushed, split or in an injectable form.
The risk of harm is also influenced by who is handling the drug. Medicines may be handled by staff or clients. There may be employees or clients with a specific allergy who will be more at risk than others from handling certain medicines. Pregnant women will be at more risk than others from drugs with cytotoxic or reproductive toxicity. A woman may be unaware that she is pregnant for several weeks after conception, so the possibility for drugs to harm a foetus must be considered in all women of child-bearing potential.
4. Identify the hazardous medicines on your list
Now you need to bring this information together and identify the more hazardous medicines you handle, so that you can manage them better.
Given what you know from SPCs and datasheets, you should be in a position to identify which medicines are intrinsically harmful, and when the risk is increased by the formulation, task or person using the medicine. Identify those medicines on your list.
How you choose to categorise the level of risk is up to you. You can identify medicines as hazardous/non-hazardous, or use a low/medium/high risk scale, or something else. There are lots of COSHH risk assessment templates available, and there are good resources available from the Health and Safety Executive (HSE) via the link https://www.hse.gov.uk/coshh/
5. Identify controls for the hazardous medicines
Now you know your hazardous medicines, you’re ready to look at controls to reduce the likelihood of someone being exposed, or reduce the consequences if they are. When you have confidence that your controls are working and effective, the risk is being managed.
When the hazard from a medicine is high, first consider whether the drug can be eliminated or substituted by a less harmful option. Selecting a particular medicine is often something the prescriber does, but it could be practice policy to use lower risk alternatives. Are there different therapies, or alternative drugs or formulations that pose less of a risk? Can you redesign tasks to minimise handling?
When eliminaton or substitution are not options, consider engineering controls. These include equipment to protect users, such as extraction and ventilation systems. Engineering controls are reliable but still not as reliable as eliminating the hazard altogether.
If engineering controls are not an option consider administrative controls, which might include policies and procedures, warnings, labels and signs, training and awareness; and, finally, personal protective equipment (PPE).
The hierarchy of controls helps you think about how strong and reliable a control may be. You should consider controls in this order, with elimination being the most effective and PPE being the least effective. Although people often default to administrative controls and PPE, remember that they are among the least reliable. Try to eliminate and substitute where you can.
The UK HSE hierarchy of controls:
Elimination – physically remove the hazard
Substitution – replace the hazard
Engineering controls – isolate people from the hazard
Administrative controls – change the way people work
Personal Protective Equipment (PPE) – protect the worker with equipment
6. Work with staff
Ultimately, it needs to be made easy for practice staff to know which medicines pose a risk, and why, and what precautions to follow. Talk to staff about handling precautions. It is good practice to treat all medicines as potentially harmful, wearing gloves when handling, and washing hands afterwards, but staff need to know about the medicines that require special handling and any procedures that apply.
You might consider using warnings, labels or storage methods that help staff distinguish the different medicine hazards, for example:
Label shelves, or have sections of the shelves set aside for specific hazardous products
Coloured warning labels on products, or on the shelf, along with a guide to what the labels mean
Isolate specific medicines in marked containers or boxes, with clear warnings and precautions
Locked storage for the highest risks products
Computer warnings and automatic warnings on dispensing labels
Staff and client information sheets for specific high-risk medicines
Practices need information from staff as well. The practice will need to know if someone is pregnant (or has the potential to become pregnant), and if anyone has allergies or intolerances that could be triggered by exposure to medicines.
7. Keep records and keep up to date
Finally, it is important to maintain your list, and keep a record of your risk assessment of your medicines. Keeping up to date with medicines is essential. New licensed products come along all the time and SPCs are updated frequently. Have a process for identifying and evaluating new products as they become available. Veterinary Prescriber’s monthly Medicines News will help you keep up to date. See the related module: How to keep up to date on medicines
Medicines risk assessment case studies
Cases study 1: Long-acting ear treatment
You are researching a long-acting ear treatment on your list. The treatment is proving very effective and popular. Although vets have only been administering it during consultations, some clients have asked for it to be dispensed, to administer at home.
The SPC for the product says this: “The veterinary medicinal product has serious eye irritation potential. Accidental eye exposure may occur when the dog shakes its head during or just after administration. To avoid this risk for the owners, it is recommended that this veterinary product is administered only by veterinarians or under their close supervision. Appropriate measures (e.g. wearing safety glasses during administration, massaging the ear canal well after administration to ensure even distribution of product, restraining the dog after administration) are needed to avoid exposure to the eyes”
What could you do?
You decide to take some actions to minimise harm:
The practice policy will be that the treatment is not dispensed for home use.
Staff will wear eye protection when administering the product.
Clients will be asked to wear eye protection, or to leave the consultation room while it is administered.
This policy will be updated on the practice computer and communicated to staff.
You update your risk assessment and take the actions.
Case study 2: Nerve growth factor inhibitor injection for osteoarthritis pain
One of the products on your list is a nerve growth factor inhibitor that is used for the relief of osteoarthritis pain. The SPC gives the following information:
“The importance of nerve growth factor in ensuring normal foetal nervous system development is well-established and laboratory studies … have shown evidence of reproductive and developmental toxicity. Pregnant women, women trying to conceive and breastfeeding women should take extreme care to avoid accidental self-injection.”
There are some serious hazards here. Your choices are limited as the practice happens to be all-female. What are your options?
You could decide to not use the medicine at the practice, offering alternatives instead.
You could decide to use the medicine only as a last resort and under strict controls.
Discuss the hazard with the team and introduce controls.
You discuss the issues with staff and together agree the following:
It will be presumed that any woman of reproductive age is at risk.
Staff who are pregnant, might be pregnant, are trying to conceive or are breastfeeding will not be asked to handle the medicines.
Animals being injected will not be held by owners, to reduce risk of accidental injection.
All nerve growth factor products will be kept in a lidded, clear-plastic box in the dispensary fridge. The box will be clearly labelled with the hazard and precautions including action to take in the event of accidental injection into the person giving the injection or holding the animal.
You update your risk assessment and take these actions.
Case study 3: Antibiotic tablets
You are researching one of the antibiotics on your list. Under “Operator Warning” the SPC gives the following information.
“Penicillins and cephalosporins may cause hypersensitivity (allergy) following injection, inhalation, ingestion or skin contact. Hypersensitivity to penicillins may lead to cross reaction to cephalosporins and vice-versa. Allergic reaction to these substances may occasionally be serious. Do not handle this product if you know you are sensitised, or if you have been advised not to work with such preparations. Wash hands after use.”
The product may be hazardous to those with an allergy to penicillin. The medicine is regularly dispensed to clients. Only this morning a client asked if it was okay to crush the tablet to give in food because the pet is hard to tablet. You decide that some special precautions are needed to protect staff and clients from the medicine.
What could you do?
You could decide to have a section of shelving in the dispensary dedicated to penicillin-containing medicines, with specific cautions and instructions attached to the shelf.
You could add warnings to the dispensing information on the computer, reminding vets to ask clients about penicillin allergy.
If a client thinks they have an allergy to penicillin, the vet will recommend alternatives, or that someone else doses the animal, and only recommend PPE for clients if there is no other alternative. Clients with a penicillin allergy will be asked not to crush tablets.
Printed labels will have penicillin allergy warnings and handling information.
You could plan training on penicillin medicines at the next staff meeting.
Once you make your choice of controls update your risk assessment with these actions, and then complete the actions.
Later that week you carry out some training at a staff meeting. As you explain about penicillin allergies a student nurse raises her hand. She says she’s not sure if she’s penicillin-allergic, but she does remember having a bad reaction as a child. She asks if she can clean up vomit if an animal is on penicillin. You realise that staff have not been asked about allergies.
You talk about what the right approach would be for cleaning up. The staff agree that the kennel needs to be clearly marked for penicillin risk, and that in the event of an animal vomoting the student nurse can ask someone else to clean up. If no-one is available, then barrier nursing PPE may be worn.
You agree to add a questionnaire about allergies and sensitivities to induction training.
You add these precautions to your risk assessment and complete the actions.
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How we produced this module
Veterinary Prescriber’s modules start with a detailed outline and electronic literature search. We commission a collaborating author, who is a specialist in the module topic, to write a draft module. The collaborating authors on this module were Andrea Tarr, Director, Veterinary Prescriber and Simon Robinson, Director, Operability.co.uk. Drafts are circulated unsigned to a wide range of commentators, include practising first-opinion vets, and other topic specialists. Commentators can raise points about the interpretation of evidence, ask questions that are important to clinical practice, and present alternative viewpoints. There is a rigorous editing and checking process and the result is a module that is evidence-based, impartial and relevant to clinical practice.