MODULE 18: Management of Chemical, Cytotoxic, Pharmaceutical and Radioactive Wastes

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MODULE 18Management of Chemical, Cytotoxic,
Pharmaceutical and Radioactive Wastes
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Module Overview

• Describe sources and types of chemical,
  cytotoxic, pharmaceutical, and radioactive wastes
  in a healthcare setting
• Discuss risks associated with exposure to these
  specific wastes
• Describe all aspects of management of these
  specific wastes
• Describe treatment and disposal methods

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Learning Objectives

• Identify hazardous (non-infectious) wastes in a
  healthcare facility
• Identify key steps in collection, handling,
  storage, transport, treatment and disposal of
  these wastes

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Sources Examples of Hazardous (Non-Infectious)
Wastes

• Examples of Sources
• Chemicals from diagnostic and experimental work
• Cleaning and disinfecting compounds
• Agents used for chemotherapy
• Drugs that are no longer required
• Waste from nuclear medicine
• Examples of Wastes
• Formaldehyde (Haemodialysis)
• Photographic fixing and developing solutions
  (X-ray Department)
• Solvents and fixatives (Pathology or Histology
  Labs)
• Engine or vacuum pump oils, solvents, degreasers
  (Facility Engineering)
• Disinfectants, pesticides, rodenticides
  (Housekeeping)
• Acids, alkalis or reducing agents (Laboratory)
• Mercury (thermometers), cadmium (batteries),
  lead (Radiology)
• Gases stored under high pressure, in cans or
  cylinders (Surgical Theater)
• Ethylene oxide gas (Central Sterile Supply)
• Expired drugs, cytotoxic drugs (Pharmacy,
  Chemotherapy Ward)

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Characteristics of Chemical Waste

• Discarded solid, liquid and gaseous chemicals
  that are
• Toxic
• Corrosive
• Flammable
• Reactive
• - Explosive, water reactive, shock sensitive
• Oxidizing

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General Types of Chemical Wastes
Chemical Waste Examples
Halogenated solvents chloroform, methylene chloride, perchloroethylene, refrigerants, trichloroethylene
Non-halogenated solvents acetone, acetonitrile, ethanol, ethyl acetate, formaldehyde, isopropanol, methanol, toluene, xylenes
Halogenated disinfectants calcium hypochlorite, chlorine dioxide, iodine solutions, iodophors, sodium dichloroisocyanurate, sodium hypochlorite (bleach)
Aldehydes formaldehyde, glutaraldehydes, ortho-pthalaldehyde
Alcohols ethanol, isopropanol, phenols
Other disinfectants hydrogen peroxide, peroxyacetic acid, quarternary amines
Metals arsenic, cadmium, chromium, lead, mercury, silver
Acids acetic, chromic, hydrochloric, nitric, sulfuric
Bases ammonium hydroxide, potassium hydroxide, sodium hydroxide
Oxidizers bleach, hydrogen peroxide, potassium dichromate, potassium permanganate
Reducers Pharmaceuticals sodium bisulfate, sodium sulfite expired drugs, spilled drug, cytotoxic drugs
Miscellaneous anesthetic gases, asbestos, ethylene oxide, herbicides, paints, pesticides, waste oils
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Examples of Chemical Waste Containing Heavy Metals

• Mercury
• Thermometers, sphygmomanometers
• Cantor tubes, esophageal dilators
• Mercury switches, fluorescent lamps
• Dental amalgam
• Some formulations (e.g., Thimerosal)
• Cadmium
• Dry cell batteries
• Lead
• Radiation shielding

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Health Impacts of Chemical Exposure

• Effects on the lungs
• Cancer (asbestos, cadmium)
• Asthma (formaldehyde)
• Irritation (glutaraldehyde)
• Effects on the eyes and mucous membranes
• Irritation (formaldehyde, xylene, methyl ethyl
  ketone)
• Conjunctivitis (glutaraldehyde)
• Blurred vision (methyl alcohol)

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Health Impacts of Chemical Exposure

• Effects on the skin
• Burns (concentrated acetic acid and sodium
  hydroxide)
• Rashes, irritation (methyl ethyl ketone, other
  solvents)
• Effects on the nervous system
• Mercury, ethylene oxide, xylene, lead,
  chloroform, other chlorinated solvents, various
  organochlorine insecticides

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Health Impacts of Chemical Exposure

• Effects on the liver and kidneys
• Lead, cadmium, chloroform, tetrachloroethylene
  and other chlorinated solvents
• Effects on the reproductive system
• Various pesticides, lead, ethylene oxide
• Cancers
• Ethylene oxide, benzene, various pesticides, some
  chlorinated solvents, many cytotoxic agents

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Segregation of Chemical Waste

• Chemical Waste
• Separate from infectious waste, radioactive
  waste, and general non-risk waste
• Segregate based on compatibility
• Toxic, Corrosive, Flammable, Reactive

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Containers and Color Coding for Chemical Waste

• WHO recommendation

Waste Color and Markings Container Type
Chemical and pharmaceutical waste Brown Plastic bag or container
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Labeling of Chemical Waste

• Waste container label should have
• Name, address, telephone of the generator
• Point of generation (if applicable)
• Start date of accumulation of waste
• Estimated quantity
• Description of contents
• Waste classification
• Hazard symbols
• Precautionary statement
• Emergency contact information

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International Chemical Waste Symbols

• Toxic
• Corrosive
• Flammable

• Explosive
• Oxidizer

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Handling of Chemical Waste

• Proper personal protective equipment (PPE) should
  be used when handling hazardous chemicals
• Type of PPE required is specific for each
  chemical

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Handling of Chemical Waste

• Appropriate transferring methods must be used
• Bonding, grounding, and explosion proof devices
  for flammable waste
• Spill kit accessible
• Different spill kits for different hazards
• All materials in the kit are hazardous after use
• Secondary containment

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On-Site Transport of Chemical Waste

• Use wheeled trolleys, containers, or carts
  designated for chemical waste transport with the
  following specifications
• Easy to load and unload
• No sharp edges that could damage waste bags or
  containers during loading and unloading
• Easy to clean
• Leak proof

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Storage of Chemical Waste

• Use a separate and enclosed area, room, or
  building
• Provide good ventilation
• Have easy access to safety shower and eyewash
  station
• Equip with a liquid or chemical proof sump
  (secondary containment in case of leaks)

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Storage of Chemical Waste

• No mixing of chemical waste (according to
  manufacturers specifications)
• Incompatible wastes should be stored separately,
  e.g. acids and bases
• Temperature should be controlled or kept within
  the acceptable range based on manufacturers
  requirements

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Sample Sketch of a Chemical Waste Storage Area
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Storage of Chemical Waste

• Storage rooms and facilities should be labeled on
  the exterior with a sign
• - NO ENTRY Hazardous waste
• Other symbols if needed
• No Smoking
• No Eating or Drinking

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Off-Site Transport

• Transport vehicles should meet basic requirements
• E.g., well maintained, bulkhead to separate
  driver from vehicle load, system to secure load,
  proper placards and markings including hazard
  symbol and emergency contacts, spill kit, easy to
  decontaminate, etc.
• Driver should be trained on
• Laws, risks, safe handling methods, labeling,
  documentation and emergency procedures
• Consignment or manifest system

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Treatment of Chemical Waste

• Chemical and Physical Treatment
• Neutralization
• Detoxification
• Chemical reduction or oxidation
• Electrolytic oxidation
• Hydrogenation, hydrolysis
• Biological Treatment
• Biodegradation
• Thermal Treatment
• High-temperatureincineration with air pollution
  control

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Treatment of Chemical Waste in Low-Income
Countries

• Encapsulation
• Inertization with cement
• Burial of encapsulated or inertized waste in
  engineered, controlled and secure landfills
• Return of chemicals to manufacturers

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Chemical Wastes Containing Heavy Metals

• Chemical Wastes containing toxic metals, in
  general
• Should not be burned or disposed in dumpsites
• Some heavy metals, like silver in x-ray
  processing, can be recovered
• Return to supplier for reprocessing or disposal
  if possible
• If no options currently exist, store the waste
  safely in a medium-term storage site
• Refer to the Secretariat of the Basel
  Conventions guidelines on the environmentally
  sound management or reclamation of metals
  including mercury and lead
• Mercury
• Develop safe clean-up, handling and storage
  procedures
• Sequester mercury waste safely in a long-term
  storage facility
• Reduce unnecessary use of mercury equipment
• Replace mercury-containing products with
  mercury-free alternatives
• Develop plans to become a mercury-free facility
• Cadmium and Lead
• Send to facilities that specialize in recovery of
  heavy metals
• Return to suppliers if possible
• Send to a treatment, storage and disposal
  facility for hazardous industrial waste

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Chemical Waste Management

• Integrate chemical waste management into the HCWM
  plan, program and organization
• Identify chemical waste sources and hazards
• Control hazards by using less hazardous
  materials, modifying equipment to reduce
  exposures, implementing safe practices, PPE and
  administrative controls
• Train workers on the proper use of PPE
• Provide workers with information such as material
  safety data sheets (MSDS) and international
  chemical safety cards (ICSC)
• Comply with the countrys chemical waste
  regulations
• Develop strategies for waste minimization

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Workers Right to Know

• Principle 10 of the Rio Declaration on
  Environment and Development
• Each individual shall have appropriate access to
  information on hazardous materials and
  activities .
• Principle 10 is embodied in many national and
  regional laws on Workers Right To Know about
  the hazards of chemicals they are working with
• Facilities can provide chemical hazard
  information by making available or International
  Chemical Safety Cards or Safety Data Sheets
  (SDSs), which are also called Material Safety
  Data Sheets (MSDSs)

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Safety Data Sheets

• Sections of a safety data sheet
• Identification
• Hazard identification
• First-aid measures
• Fire-fighting measures
• Accidental release measures
• Handling and storage
• Exposure controls/personal protection
• Exposure controls/personal protection

1. Physical and chemical properties
2. Stability and reactivity
3. Toxicological information
4. Ecological information
5. Disposal considerations
6. Transport considerations
7. Regulatory information
8. Other information, including date

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Example of an ICSC
ICSCs can be found at http//www.ilo.org/dyn/icsc
/showcard.home
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Example of a Safety Data Sheet
MSDSs can be found on the Internet or obtained
from manufacturers.
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Chemical Waste Minimization

• Source Reduction (most desirable method of waste
  minimization)
• Segregate hazardous chemical waste
• Evaluate possible substitutions using less
  hazardous or non-hazardous materials
• Use steam cleaning or non-toxic cleaners
• Control the inventory of chemicals
• Minimize unnecessary dilution of wastes
• Develop plans for a mercury phase-out

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Chemical Waste Minimization

• Recycling
• Select vendors that are willing to reprocess or
  recycle their products
• Use a silver recovery unit for photographic waste
• Use a distillation column to recover solvents
• Purchase compressed gas cylinders from
  manufacturers who accept return of empty or
  partially used cylinders

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Chemotherapeutic Waste

• Chemotherapeutic waste waste generated from the
  use of chemical agents for treatment, especially
  cancer therapy
• Cytotoxic agents substances capable of killing
  or stopping the growth of cells
• Cytostatic agents capable of suppressing growth
  and multiplication of cells
• Antineoplastic agents inhibiting the
  development of abnormal tissue growth
• Genotoxic agents capable of inducing genetic
  mutation
• Teratogenic agents capable of causing defects
  in an embryo or fetus

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Examples of Cytotoxic Waste

• Examples of sources
• Contaminated materials from drug preparation
  including vials and syringes
• Contaminated materials from drug administration
  including gloves, gauze, needles
• Examples of specific agents
• Alkylating agents (e.g., mechlorethamine,
  chlorambucil, cyclophosphamide, ifosfamide,
  melphalan, streptozocin, carmustine, busulfan,
  dacarbazine, thiotepa cisplatin)
• Antimetabolites (e.g., 5-fluorouracil,
  methotrexate)
• Anti-tumor antibiotics (daunorubicin,
  doxorubicin, bleomycin)
• Topoisomerase inhibitors (etoposide, teniposide)
• Mitotic inhibitors (paclitaxel, vinblastine,
  vincristine)

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Segregation of Cytotoxic Waste

• Cytotoxic/Genotoxic Waste
• Should be stored separately from other waste in
  designated secure location
• Collect in strong containers
• Containers should be leak-proof
• Clearly label containers cytotoxic wastes
• Do not dispose in dumpsites or discharged into
  sewerage systems

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Treatment and Disposal of Chemotherapeutic Waste

• Chemical degradation
• Convert chemo waste into non-toxic residues by
  alkaline hydrolysis, chemical oxidation with
  potassium permanganate or sulfuric acid,
  denitrosation with hydrobromic acid, or other
  effective methods for the particular type of
  cytotoxic waste
• High-temperature incineration with air pollution
  control
• Options for low-income countries
• UNDP GEF technology developed in Argentina
  www.gefmedwaste.org
• Safely package and return to original supplier
• Encapsulation as a last resort
• Do not disposed in dumpsites nor discharged into
  sewer systems

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Chemotherapeutic Waste Minimization

• Segregate chemotherapy wastes through worker
  training and separate waste containers
• Use degradable chemo agents instead of
  environmentally persistent agents
• Purchase drug volumes based on need
• Return expired agents to manufacturer
• Develop spill containment and clean-up procedures
  that minimize waste clean-up volume

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Characteristics of Radioactive Wastes

• Waste contaminated with radionuclides
• Produced as a result of
• in-vitro analysis of body tissue and fluid
• in-vivo organ imaging and tumor localization
• investigative and therapeutic practices
• Can be sealed (encapsulated in pins, seeds or
  needles) or unsealed (liquids administered
  directly)
• Some have relatively short half-lives causing
  them to lose activity quickly (e.g.,
  technitium-99m 6 hours iodine-123 13 hours
  phosphorus-32 14 days)
• Others have long half-lives (carbon-14 5730
  years)

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Sources of Radioactive Wastes in Healthcare

• Sealed sources
• Spent radionuclide generators
• Low-level solid waste, e.g. absorbent paper,
  swabs, glassware, syringes, vials
• Residues from shipments of radioactive material
  and unwanted solutions of radionuclides intended
  for diagnostic or therapeutic use
• Liquid immiscible with water, such as liquid
  scintillation-counting
• Residues used in radioimmunoassay, and
  contaminated pump oil
• Waste from spills and decontamination of
  radioactive spills
• Excreta from patients treated or tested with
  unsealed radionuclides
• Low-level liquid waste, e.g. from washing
  apparatus
• Gases and exhausts from stores and fume cupboards

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Health Risks of Radioactive Waste

• Health impacts determined by type and extent of
  exposure to ionizing radiation
• Chromosomal damage
• Headaches, dizziness, vomiting
• Tissue destruction, hemorrhage, hair loss,
  diarrhea, death at high doses
• An extreme case from Brazil (1988)
• Sealed radioactive source was removed from a
  radiotherapy institute and broken open 249
  people exposed, several died or suffered severe
  health problems

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Containers for Radioactive Wastes

• Low-level radioactive infectious waste (swabs,
  syringes) may be collected in bags or containers
• There is no recommended color code for
  radioactive waste containers
• Containers should have the radioactive symbol

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Segregation of Radioactive Waste

• Separate radioactive wastes based on
• Half-life
• Short-lived (lt60 days) versus long-lived (gt60
  days)
• Activity and radionuclide content
• Physical and chemical form
• Liquid aqueous and organic
• Non-homogeneous (e.g. contain sludge or suspended
  solids)
• Solid combustible/non-combustible and
  compactable/non-compactable
• Sealed versus non-sealed sources
• Spent sealed sources
• Waste content
• Waste containing hazardous (e.g. pathogenic,
  infectious, toxic) material

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Labeling of Radioactive Waste

• Radioactive wastes
• Radioactive waste marking and symbol
• Identification number
• Radionuclide
• Activity and date of measurement
• Period of storage required
• Origin of the waste (room, lab, etc.)
• Potential/actual hazards
• Surface dose rate and date of measurement
• Quantity (weight or volume)
• Responsible person

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Storage of Radioactive Waste

• Secure cabinet, dedicated area, room or small
  building
• Waste segregated according to the time needed for
  storage
• Extremely short half lives (lt5 days), short half
  lives (5 to 30 days), longer half lives (30 to 60
  days)
• Restricted access for safety
• Radiation shielding depending on radiological
  hazard
• Radiation monitoring and surveillance
• Fire protection
• Periodic inspections for leakage
• Recordkeeping, inventory log

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Disposal of Radioactive Waste

• Return to supplier
• Decay in Storage or storage for decay
• Store the waste for at least 10 times the
  half-life of the longest lived radionuclide in
  the waste
• Conduct a radiation survey to confirm that
  radioactivity is below the clearance level
• Disinfect mixed radioactive infectious waste
  before discarding with regular waste
• Long-term storage at an authorized radioactive
  waste disposal facility

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Radioactive Waste Minimization

• Develop a radioactive waste management plan
• Substitute long-lived radionuclides with
  short-lived radionuclides
• Substitute stable isotopes for radionuclides
  where possible
• Limit the quantity of radioactive items purchased
• Improve procedures to avoid contamination and to
  minimize the volume of waste generated

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Sources of Pharmaceutical Waste

• Expired pharmaceuticals
• Discontinued drugs
• IV preparations
• Partially used vials and syringes
• Compounding of drugs
• Breakage and spills of pharmaceuticals
• Unused single-dose repackaged drugs
• Patients personal medications

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Characteristics of Pharmaceutical Waste

• Pharmaceuticals can be
• Acutely hazardous (e.g., arsenic trioxide,
  epinephrine, nitroglycerin, warfarin gt0.3)
• Toxic (e.g., barium, chloral hydrate, chloroform,
  chlorambucil, cyclophosphamide, mitomycin C,
  streptozotocin, lindane, phenol, thimerosal)
• Flammable or ignitable (e.g., isopropanol,
  paregoric, collodion-based preparations)
• Corrosive (e.g., acetic acid used for compounding)

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Environmental Impact of Pharmaceutical Waste

• Pharmaceuticals are present in most hospital
  wastewater
• More than 100 different types of pharmaceuticals
  or their metabolites are found in water bodies in
  Europe and the U.S.
• Some pharmaceuticals can seep into the
  groundwater
• Environmental concentrations could affect fish
  and other wildlife
• Antibiotics found in streams worldwide raise
  concerns of the possible rise of
  antibiotic-resistant organisms

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Segregation of Pharmaceutical Waste

• Pharmaceutical Waste
• Should be segregated from other infectious and
  radioactive wastes
• National and local regulations must be followed

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Treatment and Disposal of Pharmaceutical Waste

• Chemical Treatment
• Chemical Absorption
• Denaturing (e.g., alkaline hydrolysis)
• High Temperature Incineration
• Recovery of active pharmaceutical ingredients
  through solvent extraction, separation,
  distillation, filtration, etc.

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Disposal of Pharmaceutical Waste in Low-Income
Countries

• Reverse distribution (return to supplier)
• Safe burial on hospital premises
• Encapsulation or inertization
• Solid, liquid, or semi-liquid waste can be
  encapsulated in metal drums
• Solids ground up mixed with cement, lime and
  water made into pellets or blocks
• Landfill disposal
• Landfilling large quantities of pharmaceuticals
  is not recommended, unless waste is encapsulated
  and disposed in a sanitary landfill where there
  is no risk of leaching into the groundwater
• Discharge to a sewer
• Only for relatively mild liquid or semi-liquids
  (vitamins, cough syrups, eye drops, saline
  solution, glucose, electrolytes, etc.)
• Discharge into a large flow of water and into
  municipal sanitary sewers
• Antibiotics and cytotoxic drugs should not be
  discharged in a sewer

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Pharmaceutical Waste Minimization

• Good inventory control
• Increase inventory turnover
• Apply inventory control strategies (e.g., ABC
  classification, First In First Out, Just-In-Time
  management, etc.)
• Avoiding unnecessary prescriptions, especially
  antibiotics
• Reformulation of drugs

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Discussion

• What are some sources of chemical, cytotoxic, and
  pharmaceutical wastes in your facility? What are
  some examples of these healthcare wastes that may
  occur both inside and outside of your facility?
  What are some major hazards and risks that are
  posed by these wastes?
• What are some sources of radioactive wastes in
  your facility? Give some examples, as well as
  their hazards and risks.
• How does your facility segregate chemical and
  pharmaceutical wastes? What about specific
  wastes that have cytotoxic and/or genotoxic
  properties? What handling and safety procedures
  are followed by those who deal directly with the
  wastes?

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Discussion

• How does your facility store chemical, cytotoxic,
  pharmaceutical, and radioactive wastes? What
  treatment and disposal methods does it use or has
  it used in the past for each category of waste?
• What are country/region-specific policies and
  guidelines for chemical and radioactive waste
  management? What about international guidelines
  specifically meant for radioactive wastes? Is
  your facility able to follow these guidelines?
• How does your facility regulate mercury? Are
  there plans to use alternative sources in place
  of mercury and to eventually phase out its use in
  most medical equipment?