Administration and Hazardous Drug List – Protocol Change

Shared on behalf of Carina Desramaux, Manager, Pharmacy and Andrea Raynak, Director, Nursing Practice


In follow-up to the memo circulated on February 5, 2024, please note that new protocols have been implemented based on guidance with The Safe Pharmaceutical Handling Evaluation Collaborative newly created framework.

The updated guidance has been incorporated into our existing policy SAF-2-04 and renamed to Hazardous Drugs – Safe Handling (see attached).

The revised policy is in accordance to recommendations and best practice and includes:

  • Categories and Definitions of Hazardous drugs with direct links to the most up to date list
  • Risks and Labelling
  • Detailed information on the safe handling of hazardous drugs (i.e., associated personal protective equipment, disposal and emergency management).

A complete list of All Hazardous Drugs are included with this memo (see attached).

To support this change in practice, a Quick Reference Guide has been created and is attached. Additional educational materials have been created and will be distributed as we initiate hospital wide education beginning on Monday, February 12, 2024.

Any questions about this memo can be directed to your Manager.

We thank you for your cooperation throughout these updates.