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Workbook 5: Drug Disposal & Chemicals

Introduction

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Our concerns about chemicals and pharmaceuticals in the doctor’s office are complex. There are so many chemicals in our offices, some of which might be found in any office and others of which are special to the healthcare world. Example of common office chemicals would be photocopier toner, cleaning supplies, and insect sprays. Chemicals unique to a doctor’s office include sterilizing agents and pharmaceuticals.

For each chemical, there are many questions we might ask. Is this chemical harmful to those of us in the office? Is the chemical manufactured and packaged using methods that are environmentally sound? Is the chemical stored safely? Is someone in the office responsible for managing it? Is the chemical outdated and perhaps now dangerous? Does this chemical persist in our environment or does it quickly degrade harmlessly?

Do we really need this chemical in the office? Is there a healthier or ‘greener’ alternative? If we do need it, can we use less of it and save money? Is the packaging recyclable or reusable?

Do we know how to discard chemicals responsibly?  The toilet is not the right answer because chemicals and medicines flushed away end up in our rivers, lakes, and drinking water.

We worry about keeping clean in the medical office. But sometimes we overdo “clean” by using too many chemicals or too toxic chemicals in the office and home.  Bleach is often the first chemical we seek for a bad spill, but bleach is quite toxic, is certainly overused in hospitals and offices, and many experts say that bleach is the reason why nurses worldwide are the most likely professionals to develop adult-onset asthma.  For a sensible guide to cleaning, see the My Green Doctor blog, http://www.mygreendoctor.org/green-cleaning-keeps-toxins-out-heres-how/

The internet has abundant resources from the chemical industry, hospital organizations (way ahead of doctor offices on this subject), and government.  We will guide you through them in this workbook.   Avoiding unnecessary chemical exposures in the office and at home may be another way to save money.

If you have not yet done so, please register now with the Green Doctor Office Program before you proceed further.

Drug Disposal and Chemical Action Steps

Your Green Doctor Office Team will begin by making an informal list – an inventory – of the types of chemicals and medicines in your office.  If you have outdoor spaces, this will include the fertilizers or pesticides for the landscaping of your building. The Green Team may want to divide up the inventory responsibilities among Team members.

Your list should include the name of each chemical and an estimate of the amount that is stored or used in one year. Your Green Team will then be ready to decide which action steps your office might undertake.  Your Team might design an entire Improvement Plan at the start, or choose a few action steps to get started, and then develop your Plan more fully over several months after you have success with your first steps.

The types of chemicals generally found in a doctor office are presented in five categories:

  • A. Chemicals related to a general office
  • B. Office cleaning products
  • C. Pest control chemicals
  • D. Chemicals related to patient care
  • E. Pharmaceuticals, including medicine samples

Take some time to consider each item in your office and to decide.

We will walk you through a list of action steps you can take in each of these categories.  We provide a lot of time-tested ideas in this Workbook, ideas of what sorts of questions and solutions have been discovered by other offices and other businesses.The creation of your Improvement Plan should be a group effort of the Green Team members since everyone on the Team will share the responsibility for making the Improvement Plan work. Many times we will challenge your Green Team to come up with your own ideas by asking you, “What else?”  Please email us your “What Else” ideas for us to add to the Workbook. Once the Team selects to undertake a particular action step for the office, check the “To Do” box next to that action step.  When you have achieved your goals for that action step, check additionally the ‘Done’ box.

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Chemicals Related to a General Office

Chemicals around the desk:   Visit the various desks around the office to see what chemicals lurk at the reception desk, the nursing station, and on the office manager’s desk.  Take some time to consider each item in your office, asking some of the questions below and considering some changes to propose to your Green Team.

Wall coverings, carpets & furniture:

  • All office and building managers should read the information on the website of Hospitals for a Healthy Environment (http:/cms.h2e-online.org/ee/facilities/materials-of-concern).
  • Adopt a policy for office and building managers to work with contractors to purchase only Green materials (such as Green Seal products) in redecorating, remodeling or repairing the office.
  • Recycle after use building materials, furniture, paints, and other construction chemicals.
  • Adopt a policy on management of mercury (see below with ìChemicals Related to Patient Care).

Photocopiers, faxes & printers:

  • Adopt a policy to reduce copying, faxing & printing.  Use double-sided printing & draft mode. Teach everyone in the office how to do this.   See this topic in ìWorkbook 4:  Solid Waste & Recycling.

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Office Cleaning Supplies

  • Adopt a policy that all office cleaning personnel and building managers should read the useful “10- Step Guide to Green Cleaning” from Hospitals for a Healthy Environment, found here.
  • Adopt an office policy to use only Green chemicals endorsed by Green Seal , EcoLogo, or Environmental Choice.  Products to identify in your office include general cleaners, toilet bowl cleaners, carpet cleaners, glass cleaners, floor strippers and waxes.   Often the vendor who sells and delivers your cleaning products will already know about these products and be pleased to help.
  • Adopt a policy to use only Green hand cleansers in the public areas such as restrooms, and to never use products containing triclosan.
  • Display signs stating that you use only environmentally-certified cleaning products for the safety of your patients and of the environment.
  • Prepare an informational handout on green cleaning for patients and staff.  Put this helpful information in your waiting room; consider enclosing it with your bills mailed to patients.
  • Makes copies of the My Green Doctor blog concerning safe cleaning; give these to your office staff for their homes and to your janitorial staff.  Leave copies in the waiting room for patients.  http://www.mygreendoctor.org/green-cleaning-keeps-toxins-out-heres-how/

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Pest Control Chemicals>

  • All office and building managers should read the easy guide from Hospitals for a Healthy Environment relevant to pest control chemicals:  Read more.
  • Adopt an “Integrated Pest Management” program in order to save money and minimize the use of toxic chemicals in the doctor office.
  • Review pest management contracts to avoid scheduled preventative chemical applications.
  • Install insect “bait stations” under desks and cabinets rather than spraying chemicals.
  • Inventory annually your landscape pesticide use and adopt a best-practice standard with your landscape pest management vendor.
  • Prepare an informational handout on pest management in the home for patients and staff.
  • Prepare an informational handout on pesticide use in the garden for patients and staff.

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Chemicals Related to Patient Care

  • For hazardous waste spills such as blood, adopt a “best practice” national standard to minimize toxic chemical exposure to patients and office workers.  A body fluid spill cleanup policy is required by OSHA.
  • Review the manufacturers recommended procedures for cleaning medical devices; adopt the least toxic methodologies allowed.  Review the adequacy of the doctor office training of your staff, compliance with safety measures, adequacy of ventilation, and monitoring of exposure levels.
  • Take an inventory of mercury containing devices.  Adopt a strategy and timetable to minimize or remove the risk of mercury-containing devices.  Consider particularly sphygmomanometers, thermometers, and thermostats.
  • Adopt procedures for hazardous waste disposal of devices and bottles containing mercury.  Examples include batteries, pesticides, thermometers, thermostats, fluorescent bulbs, and cathode ray tubes.
  •  Prepare an informational handout on mercury in the home for patients and staff.

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Pharmaceuticals

  • Adopt medication disposal procedures for your office, including a ìDo Not Flushî policy and post signs at sites where medications are stored.
  • Contact your city or county to learn the disposal rules for medications and especially for controlled substances.  You may fine online information from your local recycling coordinator or a household hazardous waste collection center.
  • Prepare an informational handout for patients and the office staff concerning the safe disposal of liquid and solid pharmaceuticals.

Tips for Success

Your Improvement Plan consists of the Action Steps that you choose to adopt for the office.

For each action step:

  • Record the conditions in your office before you start taking action.  For example, do you have complaints about conditions in the office (smells, headache, and nausea); do you have complaints about pests such as ants, cockroaches, or other insects?
  • Establish specific, measurable, date-certain targets for what you want to accomplish such as, ìWe will purchase only green-certified cleaning products by June 1î, or ìWe will always dispose of pharmaceuticals properly by January 1.î
  • Agree on a leader for each Action Step.
  • Agree on the responsibilities of each person in the office.
  • If needed, obtain agreement or approval from the office manager or chief executive.
  • Communicate with your office colleagues.  Listen for ideas and try to elicit helpful criticisms.
  • Educate your patients, families & community.   Which ideas could be shared with your own families or with your patients?  Part of the Green Team’s Improvement Plan must include an education plan.  Your waiting room can become a site for education.
  • Reassess the Plan after a reasonable period.

Background Information

 

  • Chemicals from construction and decorating materials:  Materials used in the construction or decoration of an office may release chemicals called off-gasses that can be harmful or unpleasant for many years.  These construction items include sheetrock, paint, carpets, carpet adhesives, upholstery, furniture finishes, and electronic equipment.
  • Low-level exposure to paint fumes may burn the eyes, nose, throat, and skin; they may cause headaches, dizziness, or nausea. These symptoms are generally mild.  High-level exposure to some paint components, even for a short period of time, can cause severe and lasting impacts such as kidney, liver, or respiratory problems. Some oil-based paints contain formaldehyde and benzene which are carcinogenic, while others contain heavy metals and phthalates that are human and ecosystem toxins.
  • Cleaning Products:  Many cleaning products are irritating to patients.  Some involve hazardous processes in their manufacture, or leave long-term sequelae with their disposal.  The Centers for Disease Control and Prevention has stated that it is not helpful to try to disinfect our offices or all of the surfaces that come in contact with patients.  We often waste time and money with excessive cleaning, and may even inflict harm.  A comprehensive guide to this topic is provided by Hospitals for a Healthy Environment:  here.
  • Pest Control and Pesticides:   Hospitals are way ahead of doctor offices in the area of pest control.  They have to be since JCAHO insists on it.  The mantra in this area is called, “Integrated Pest Management”. IPM uses pesticide and non-pesticide techniques.  The goal is to minimize the cost and risk of chemical use.  Therefore, regularly scheduled pesticide applications and “protective barrier” applications are NOT part of IPM; indeed scheduled pesticide contracts can lead to insects that are resistant to pesticides.
  • Chemicals Related to Patient Care:  The chemicals most likely to contact patients are those which must be the safest and cleanest.  Chemicals of concern include cleaning products and mercury.  In some cases, specific potentially toxic chemicals must be used such as for some equipment sterilization processes.  When this is the case, the doctor office must monitor the proper education of its employees and maintain strict safety standards.
  • Mercury, found in many older medical devices and thermostats, is a potent neurotoxin.  OSHA’s requirements for cleaning up a mercury spill are very strict broken thermometer can cost $5000 to $200,000 to clean up.  Every doctor office should assess for mercury-containing devices and replace any of these if possible.  Mercury is not avoidable in fluorescent light bulbs and some batteries.  Proper disposal is essential for such mercury-containing products.  Every community in the US has drop-off sites for disposing mercury-containing devices and bulbs. Find a comprehensive guide: here.
  • Pharmaceuticals:  Flushing expired medicines down the toilet creates severe problems for the environment.  Pharmaceuticals, including antibiotics, can be found in the drinking water supplies of at least 41 million Americans. A campaign to inform Americans was launched in 2008 called “SMARXT. DISPOSAL” with the web link provided here.
  • Do not flush unused medications or pour them down a sink or drain.  Consumers were once advised to flush their expired or unused medications; however, recent studies report that this harms the environment.  While the rule of thumb is not to flush, the Food and Drug Administration (FDA) has determined that certain medications should be flushed due to their abuse potential.  Doctor offices should encourage their patients to read the instructions on their medication labels and to talk to their pharmacist.
  • Most unused medication should be disposed in the household trash.  It is best to destroy medicines before discarding them. Care must be taken to protect children and pets from potentially negative effects.  To do this, pour liquid medications into a sealable plastic bag , add kitty litter, sawdust, or coffee grounds to make the medicine less appealing, and seal the plastic bag before putting it in the trash.
  •  If a medication is a solid (pill, liquid capsule, etc.), crush it or add water to dissolve it before putting it in the household trash.
  • Remove and destroy identifying personal patient information from discarded medication containers.
  • Check for approved state and local Collection Programs.  In certain states, but not in Florida, you may be able to take your unused medications to a neighborhood community pharmacy.
  • Always follow your state’s laws and be particularly aware of those laws concerning drugs that may be abused, such as narcotics.  Generally the law requires that these be returned to a pharmacist for disposal.

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