Which hospice medications are classified as hazardous drugs? 

Very few of the drugs in a standard comfort kit are. To see why, separate two questions that often get blurred: how risky is the drug for the patient, and how risky is it for the person handling it? 

What makes a drug hazardous under NIOSH? 

NIOSH counts a drug as hazardous when it is FDA-approved and either carries manufacturer special handling instructions in its package insert or has been identified as a worker's health hazard. The hazard categories are: 

• Carcinogenicity: The drug or a close relative is classified as a human carcinogen by IARC or similar bodies or shows carcinogenic potential in animal studies. 

• Developmental and reproductive toxicity: Birth defects, impaired fertility, or adverse pregnancy outcomes at therapeutic doses. 

• Genotoxicity: The drug damages DNA or chromosomes. 

• Organ toxicity at low doses: Serious organ damage at doses comparable to what a worker might absorb. 

Meeting any one criterion is enough. These criteria describe risk to the worker, not the patient's side-effect profile. 

Which hospice drugs appear on the NIOSH 2024 list? 

Verified drug listings: NIOSH published the update in December 2024. It added 25 drugs (12 with manufacturer special handling information), removed seven, and cut the list from three tables to two. It replaces the 2016 version. In our review, the standard comfort-kit drugs above are not on it. Hospice-relevant listings are more likely to be oral antineoplastics and hormonal or reproductive-risk agents the patient was already taking at admission. Verify against the PDF and remember that NIOSH reviewed drugs within a fixed window, so newer approvals with handling instructions may not be reflected. 

Occupational exposure precautions: For listed drugs, exposure mostly comes through skin contact, dust from crushed tablets, and body fluids from a patient who recently took the drug (urine, stool, vomit, and sweat can carry the drug or metabolites). Standard practice is gloves rated for hazardous drugs, a gown when contamination is possible, no crushing unless unavoidable, and handwashing after glove removal. 

Considerations for pregnant workers or those planning pregnancy: USP <800> expects employers to have a policy for staff who are pregnant, breastfeeding, or trying to conceive, including the option of reassignment away from reproductive-risk drugs. Tell staff what is on the hazardous drug list before their first assignment, not after. 

Therapeutic risk vs. occupational hazard 

Patient side effects versus occupational classification. Morphine can stop a patient’s breathing if the dose is wrong. That is a therapeutic risk: it arises when the intended patient absorbs a pharmacologic dose. A hazardous drug listing asks a different question: does ordinary workplace contact cause cancer, birth defects, DNA damage, or organ injury? 

Why does respiratory depression not automatically establish hazardous drug status? Sedation and respiratory depression are dose-dependent effects. Brief contact with intact tablets or a sealed vial doesn’t deliver a dose anywhere near that range. Opioids still demand respect, particularly concentrated fentanyl products, but the controls focus on diversion, accidental ingestion, and patch or gel contact, not the chronic-exposure measures used for chemotherapy. 

Do hospice medications need a safety data sheet? 

It depends on the drug’s form and what the worker is doing with it. 

Understanding the OSHA Hazard Communication Standard drug exemption 

The Hazard Communication Standard (29 CFR 1910.1200) exempts some drugs. Under 29 CFR 1910.1200(b)(6)(vii), that covers any drug, as defined in the Federal Food, Drug, and Cosmetic Act, in solid, final form for direct administration to the patient, such as tablets or pills. A nurse giving a patient an intact tablet from a labeled blister pack is within the exemption, so the employer doesn’t need an SDS for it under HCS. 

When does the exemption not apply? 

The exemption is narrow. It generally stops applying when: 

• The drug is a liquid or injectable: Oral concentrates, ampules, vials, and suppositories aren’t “solid, final form.” 

• Tablets are crushed or split: Creating dust or fragments changes the exposure picture, and the product is no longer being given in its final form. 

• Compounding happens: Anything prepared on site, such as a sublingual preparation made from a stock product, falls outside it. 

• A spill occurs: Cleaning up a broken bottle of morphine solution is a chemical-exposure task, not medication administration. 

Verification: The language is easy to read. Confirm with your safety officer or counsel about how it applies to your products and note that a state-plan OSHA program or accreditor may ask for more. Many hospices keep SDSs for everything that isn’t a solid oral dose, plus any drug they plan to crush. It’s a defensible policy that costs little. 

What should staff look for on drug SDS? 

SDSs follow a fixed 16-section format. Four sections matter most here: 

• Section 2, hazard identification: Look for GHS statements on reproductive toxicity, carcinogenicity, or target organ toxicity. SDSs for bulk active ingredients may appear more concerning than those for finished products, so please verify which ones you have. 

• Section 7, handling and storage: Storage temperature, incompatibilities, and handling precautions. 

• Section 8, exposure controls and personal protection: Glove type, eye protection, ventilation, and any exposure limits. 

• Section 13, disposal considerations: Whether the waste is regulated and any limits on sewer disposal. 

How should hospice staff handle hazardous drugs safely? 

USP 800 in home and facility settings 

Standard scope and applicability: USP <800> is a standard for handling hazardous drugs in healthcare settings. It covers receipt, storage, compounding, dispensing, administration, and disposal, and applies to all personnel who handle them. It took effect December 1, 2023. USP chapters gain legal force when state boards of pharmacy and other regulators adopt them, so enforcement varies by state. 

Facility versus home-health considerations: An inpatient hospice unit, or any facility with a pharmacy, falls squarely under USP <800>. The patient's home does not, because the standard is written for healthcare entities. Home visits aren't unprotected, though. OSHA's General Duty Clause still requires employers to address recognized hazards, and most hospices carry out the core practices (identification, PPE, labeled waste, spill response) into the home because their nurses bring the same risks with them. 

PPE for administering and crushing medications 

• Gloves and protective gowns: For hazardous drugs, use gloves tested to ASTM D6978 (chemotherapy-rated). Ordinary exam gloves aren't equivalent. Wear a permeation-resistant disposable gown when splashes or contamination are likely, change torn or contaminated gloves, and wash hands afterward. 

• Eye protection when indicated: Splash risk comes mainly from liquids and from pouring or drawing up solutions, so use goggles or a face shield for those tasks. 

• Task-specific exposure controls: Don't crush hazardous drug tablets if another formulation exists. If you must, use a closed-system pill crusher or similar contained method, away from food and shared surfaces. Ask the pharmacist first, since a liquid or dispersible form is often available. 

Training caregivers and family members 

Family members do most of the medication handling in home hospice and usually get far less training than staff. Keep instructions simple and repeat them. 

• Medication patch handling: Fentanyl patches are the main concern. Apply with clean, dry hands, never cut a patch, remove the old patch before applying a new one, and fold used patches sticky side to sticky side before disposal. Children have suffered serious harm from patches that stuck to them after contacting the patient. 

• Hand hygiene and avoiding unintended exposure: Wash hands after handling medications and keep drugs away from food preparation. If the patient takes a listed hazardous drug, wear gloves when handling soiled linens or waste. 

• Safe handling instructions: Give written instructions, name someone caregivers can call at any hour, and have them show you how they'd give a dose instead of only telling you. 

How should hospice medications be stored? 

Storage requirements under 42 CFR 418.106 

The CMS hospice Condition of Participation at 42 CFR 418.106 covers drugs, biologics, medical supplies, and equipment. It requires drug management policies covering ordering, administration, labeling, and handling, with different expectations for inpatient settings and the patient’s home. 

Hospice medication-management policies: Policies should be written, pharmacist-reviewed, and specific about who may handle, store, and dispose of what. A policy that lives only in the orientation of the binder won’t hold up in a survey. 

Facility and home storage considerations: Inpatient units keep medications in locked storage, with controlled substances under added security and access logs. In a home, the drugs belong to the patient, so storage becomes a teaching task: where the kit lives, who can reach it, and what to do with old or unwanted prescriptions. 

Securing controlled substances in the home 

• Lockboxes and access restrictions: Provide or recommend a lockable box for the comfort kit and any Schedule II drugs. Ask who lives or visits the home. Diversion by visitors and household members is a recognized risk at the end of life, so present the questions as a routine procedure, not suspicion. 

• Counts and documentation: Count and record on delivery, at each visit where the drugs are handled, and at death. Note the quantity, date, and who counted, and document any family member who witnessed it. 

• Applicable DEA recordkeeping requirements: DEA registrants, such as an inpatient unit with its own pharmacy or a hospice-run pharmacy, must keep inventories and receipt and dispensing records, report theft or significant loss on DEA Form 106, and use Form 41 for registrant destruction. A patient’s own home supply isn’t the hospice-registered inventory, but hospice policy usually requires equivalent counts. 

Temperature, light, and labeling 

• Manufacturer-specified storage conditions: Most hospice drugs are kept at controlled room temperature, but not all. Lorazepam injection and some suppositories need refrigeration, and certain products must be shielded from light. Follow the package to insert and keep the kit out of hot cars. 

• Original packaging and clear labels: Keep drugs in original containers with the pharmacy label showing patient name, drug, strength, and directions. Concentrated morphine should stay with its calibrated dropper or syringe, since mg-versus-mL confusion is a classic dosing error. 

• Expiration date monitoring: Check dates for delivery and at every home visit. Pull expired drugs and treat them as disposal items. 

How should hospice medications be stored? 

Storage requirements under 42 CFR 418.106 

The CMS hospice Condition of Participation at 42 CFR 418.106 covers drugs, biologicals, medical supplies, and equipment. It requires drug management policies covering ordering, administration, labeling, and handling, with different expectations for inpatient settings and the patient's home. 

Hospice medication-management policies: Policies should be written, pharmacist-reviewed, and specific about who may handle, store, and dispose of what. A policy that lives only in the orientation of the binder won't hold up in a survey. 

Facility and home storage considerations: Inpatient units keep medications in locked storage, with controlled substances under added security and access logs. In a home, the drugs belong to the patient, so storage becomes a teaching task: where the kit lives, who can reach it, and what to do with old or unwanted prescriptions. 

Securing controlled substances in the home 

• Lockboxes and access restrictions: Provide or recommend a lockable box for the comfort kit and any Schedule II drugs. Ask who lives or visits the home. Diversion by visitors and household members is a recognized risk at the end of life, so present the questions as a routine procedure, not suspicion. 

• Counts and documentation: Count and record on delivery, at each visit where the drugs are handled, and at death. Note the quantity, date, and who counted, and document any family member who witnessed it. 

• Applicable DEA recordkeeping requirements: DEA registrants, such as an inpatient unit with its own pharmacy or a hospice-run pharmacy, must keep inventories and receipt and dispensing records, report theft or significant loss on DEA Form 106, and use Form 41 for registrant destruction. A patient's own home supply isn't the hospice's registered inventory, but hospice policy usually requires equivalent counts. 

Temperature, light, and labeling 

• Manufacturer-specified storage conditions: Most hospice drugs are kept at controlled room temperature, but not all. Lorazepam injection and some suppositories need refrigeration, and certain products must be shielded from light. Follow the package to insert and keep the kit out of hot cars. 

• Original packaging and clear labels: Keep drugs in original containers with the pharmacy label showing patient name, drug, strength, and directions. Concentrated morphine should stay with its calibrated dropper or syringe, since mg-versus-mL confusion is a classic dosing error. 

• Expiration date monitoring: Check dates for delivery and at every home visit. Pull expired drugs and treat them as disposal items.

How should hospice medications be stored? 

Storage requirements under 42 CFR 418.106 

The CMS hospice Condition of Participation at 42 CFR 418.106 covers drugs, biologicals, medical supplies, and equipment. It requires drug management policies covering ordering, administration, labeling, and handling, with different expectations for inpatient settings and the patient's home. 

Hospice medication-management policies: Policies should be written, pharmacist-reviewed, and specific about who may handle, store, and dispose of what. A policy that lives only in the orientation of the binder won't hold up in a survey. 

Facility and home storage considerations: Inpatient units keep medications in locked storage, with controlled substances under added security and access logs. In a home, the drugs belong to the patient, so storage becomes a teaching task: where the kit lives, who can reach it, and what to do with old or unwanted prescriptions. 

Securing controlled substances in the home 

• Lockboxes and access restrictions: Provide or recommend a lockable box for the comfort kit and any Schedule II drugs. Ask who lives or visits the home. Diversion by visitors and household members is a recognized risk at the end of life, so present the questions as a routine procedure, not suspicion. 

• Counts and documentation: Count and record on delivery, at each visit where the drugs are handled, and at death. Note the quantity, date, and who counted, and document any family member who witnessed it. 

• Applicable DEA recordkeeping requirements: DEA registrants, such as an inpatient unit with its own pharmacy or a hospice-run pharmacy, must keep inventories and receipt and dispensing records, report theft or significant loss on DEA Form 106, and use Form 41 for registrant destruction. A patient's own home supply isn't the hospice's registered inventory, but hospice policy usually requires equivalent counts. 

Temperature, light, and labeling 

• Manufacturer-specified storage conditions: Most hospice drugs are kept at controlled room temperature, but not all. Lorazepam injection and some suppositories need refrigeration, and certain products must be shielded from light. Follow the package to insert and keep the kit out of hot cars. 

• Original packaging and clear labels: Keep drugs in original containers with the pharmacy label showing patient name, drug, strength, and directions. Concentrated morphine should stay with its calibrated dropper or syringe, since mg-versus-mL confusion is a classic dosing error. 

• Expiration date monitoring: Check dates for delivery and at every home visit. Pull expired drugs and treat them as disposal items. 

How do you dispose of hospice medications after a patient's death? 

What does the SUPPORT Act allow hospice staff to do? 

Disposal by qualifying hospice employees: Before 2018, hospice staff had no clear federal authority to dispose of deceased patient-controlled substances, and families were sent to take-back sites on their own. The SUPPORT for Patients and Communities Act (Public Law 115-271, October 2018) changed that, allowing employees of a qualified hospice program to dispose of a deceased patient's controlled substances in the home. 

Applicable legal conditions and written policies: There are conditions. The employee must be authorized under state law; the hospice must have written disposal policies, and disposal must follow applicable federal, state, and local requirements and be documented in the patient's record. State law matters here, and some states still limit who may dispose of a patient's drugs. 

Written disposal policies and family education 

42 CFR 418.106(e): CMS requires written policies for managing and disposing of controlled drugs in the patient's home. The hospice must give those policies to the patient or representative and family when controlled drugs are first ordered, discuss them, and document that it did. 

Patient and family communication: Explain what happens to leftover medication at admission, not at the bedside. Families who know the plan are less likely to keep leftover opioids "just in case," and agreement made early makes the hardest day easier. 

What disposal methods are available? 

• Authorized take-back sites: DEA-registered collectors, including some pharmacies, hospitals, and law enforcement locations, accept unwanted controlled substances through permanent kiosks and periodic events. 

• Mail-back programs: Prepaid, DEA-compliant mailers let families return drugs without traveling. 

• Drug deactivation products: Pouches and kits using activated carbon or similar agents render the drug inert, and hospices often use them at home. They should meet DEA's "non-retrievable" benchmark (21 CFR Parts 1300 and 1317), and your choice should match your written policy and state rules. 

• FDA flushing guidance: FDA keeps a short flush list of drugs with a high risk of fatal accidental exposure, including fentanyl patches and several opioid products, for use when no take-back option is readily available. It's a fallback, doesn't override state or hospice policy, and doesn't include midazolam or lorazepam. 

How is hazardous drug waste different from controlled substance disposal? 

Three frameworks overlap, and one drug can fall under more than one. 

• NIOSH hazardous drug classification concerns worker protection. It drives handling, PPE, and labeling but doesn't by itself make something regulated waste. 

• DEA controlled-substance requirements (21 CFR Part 1317) concern preventing diversion. They govern who may destroy a controlled substance and define "non-retrievable." 

• EPA hazardous waste rules under 40 CFR Part 266, Subpart P set management standards for hazardous waste pharmaceuticals at healthcare facilities, including a ban on sewering them. Whether a drug is RCRA or hazardous waste depends on EPA's own listings and characteristics, not the NIOSH list. Many NIOSH drugs aren't RCRA waste, and many RCRA wastes aren't on the NIOSH list. 

An oral chemotherapy tablet might be NIOSH-hazardous but not RCRA waste. Morphine is a DEA matter but not a NIOSH one. Warfarin may touch more than one framework. Treat each as its own question and record the answers in your policy.

What should hospice teams do after a spill or exposure? 

Spill kits and cleanup steps 

• Appropriate spill supplies: Stock chemotherapy-rated gloves, gowns, eye and face protection, absorbent pads, a scoop and scraper, sealable bags, detergent, and warning signs. A compact version can travel in the nurse’s bag. 

• Product-specific safety instructions: Follow the SDS or manufacturer instructions where they exist. Absorb liquids with pads, cover powders with damp pads so they don’t become airborne, and pick up glass with a scoop, not fingers. 

• Trained personnel: Clean with detergent and water, rinse, and dispose of all materials under your policy. Anyone who might clean a spill should learn how before they need to. 

What should staff do after exposure to accidental exposure? 

Example: Medication patch contact—if a fentanyl patch or its gel touches someone else’s skin, remove the patch and rinse it with plain water. Soap, alcohol, and solvents can increase absorption, so avoid them. Watch for sedation, slow or shallow breathing, or confusion. 

Immediate response and medical assessment. Remove contaminated clothing, flush skin or eyes with water (eyes for at least 15 minutes), and get a medical assessment. In the US, Poison Control is 1-800-222-1222. If an opioid exposure causes symptoms, call emergency services. 

Applicable exposure protocols. Follow your agency’s occupational exposure plan, which should send the worker to employee health and point to the SDS or package insert for the drug involved. 

Documentation and incident reporting

• Substance and exposure details: Drug, strength, form, route of contact, time, duration, and body area or quantity spilled. 

• Response actions: First aid given, who was notified, how the area was cleaned, and what was discarded. 

• Required follow-up: Employee health evaluation, a supervisor’s report, and, where required, reports to the DEA (loss or theft), the state, or OSHA (recordable injuries). Review each incident afterward to see what would have prevented it. 

Hospice medication safety checklist 

• Medication identification and classification: Every drug in the home or unit is identified by name, form, and DEA schedule. 

• Hazardous-drug information verification: Each drug is checked against the current NIOSH list and your facility's own list. 

• SDS access: SDSs are available for liquids, injectables, compounded items, crushed tablets, and cleaning chemicals, wherever staff work. 

• PPE selection: Correct gloves, gowns, and eye protection are stocked and matched to the task. 

• Staff and caregiver training: Staff know the hazards and spill response, and caregivers know patches, hand hygiene, and storage. 

• Secure storage: Controlled substances are locked away from children and visitors and kept under labeled conditions. 

• Controlled substance counts and records: Counts happen at delivery, at visits, and at death and are recorded. 

• Approved disposal procedures: Disposal follows your written policy, the SUPPORT Act conditions, and state rules. 

• Spill-response readiness: Kits are stocked and within reach, and staff know how to use them. 

• Incident documentation: Exposures, spills, and losses are recorded in detail and followed through.