Pharmaceutical Pollution Prevention (Pharm P2)
Wisconsin Healthcare for a Healthy Environment meeting
April 9, 2009
Presented by Barb Bickford, Wisconsin Department of Natural Resources
Why minimize pharmaceutical waste?
 Prevent pollution (air, water, land)
 Save money (purchasing, disposing)
 Save staff time (purchasing, disposing, recordkeeping, reporting, training)
 Comply with regulations and accreditation organizations
Examples from Minnesota case studies: (see PGH 10 step Blueprint, Appendix
C for details)
Example 1: A large urban hospital examined the pharmaceuticals being
wasted, and simply by adjusting their inventories on the top 10 drugs, saved
at least $80,000 per year and eliminates 100’s of lbs of drug waste.
Example 2: A small rural hospital reduced inventory and reducing packaging.
The monthly overhead in the pharmacy was reduced from $210,000/mo to
$87,000/mo. These two changes dramatically reduced the amount of waste
from expiring medications and excess stock.
How can we minimize it?
These ideas are from Step 5 of Practice GreenHealth’s 10 Step Blueprint for
Managing Pharmaceutical Waste in the United States.
 Change purchasing practices – order the dosage forms used most often and
multiples of those to achieve strengths for esoteric doses, purchase for least
packaging
 Change prescribing practices – prescribe lifestyle changes instead of drugs
when possible, prescribe less toxic drugs (e.g., single doses that don’t have
Thimerosal preservative), create and use therapeutic substitution lists
 Change systems – dispense unit doses, dispense only what is needed,
dispense automatically to get records of amounts wasted, change dispensing
devices, order drugs more often to avoid outdating, reduce inventory
 Change usage – flush chemo lines with saline before and after delivering the
chemo drug, administer prescribed dose in oral syringes instead of unit dose
cups
 Change labeling -- pre-label for home use so items can be sent home with
patients
 Monitor dating -- especially on crash carts and in areas where drugs tend to
outdate before being used, rotate stock nearing outdates to ER
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How to start?
 Gather data
o Review reverse distribution manifests
o Review hazardous waste disposal manifests
o Keep or review records of drugs being wasted by flushing
o Review any automatic drug dispensing device records
o Examine contents of crash carts
o Review pharmaceutical purchase orders and formularies
 Identify the top few drugs being wasted
 Find out why each drug is wasted
o Compare common prescribed dosages with dosage sizes of
pharmaceuticals being purchased
o Interview everyone involved with the drug: prescribing doctors,
pharmacists, purchasing, GPOs, nurses, waste disposers, waste vendors,
even patients if necessary
o Ask about motivation AND ability. Why they do things that way? What
are they able to do or not do?
o Sort out whether the reason is individual, related to groups, or to systems
or environment
 Address each reason if possible. Make it difficult to waste drugs. Make it
easy to avoid waste.
What resources are available?
Documents
o Practice GreenHealth 10 Step Blueprint for Managing Pharmaceutical
Waste in the United States -- regulations, waste minimization (see step 5
of document) and pharm P2 case studies (see appendices)
http://www.practicegreenhealth.org/page_attachments/0000/0102/Pharm
WasteBlueprint.pdf
Websites
o Minnesota Technical Assistance program, MnTAP - Case studies
http://mntap.umn.edu/health/pharm.htm
o WI Department of Natural Resources, WDNR – regulations, pharm P2
http://www.dnr.wi.gov/org/aw/wm/pharm/nonhousehold.htm
o UW Extension, Solid and Hazardous Waste Education Center, SHWEC –
links, webcasts, web pages, interns
http://www4.uwm.edu/shwec/
http://www4.uwm.edu/shwec/wh2e/pharmp2.cfm
o Practice Greenhealth – webinars, links to documents
http://www.practicegreenhealth.org
http://cms.h2e-online.org/ee/hazmat/hazmatconcern/pharma/
o Teleosis Institute (Green Pharmacy)
http://www.teleosis.org/gpp-program.php
Experts -- internal and external – see next slide
Groups (meetings, listservs, discussion fora, newsletters), e.g., WH2E
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Who can/should help? --- Everyone involved!
 Waste handlers (housekeeping, environmental services)
 Pharmacy staff
 Nurses and doctors
 Purchasing and GPOs
 Administration
 Waste vendors and consultants
 Technical assistance providers
 Interns
Pharm P2 Exercise
 Split into groups with a variety of people in each group. Pick a recorder and a
presenter.
 Review “data” (below) for your group’s situation.
 Imagine every possible reason why it might be easy to waste this drug or type
of drug, and record the reasons on the “Pharm wasting” page. Use complete
sentences if possible. Do this quickly, round robin style, i.e., go around the
circle, either state an idea or pass until no more ideas surface. Don’t judge or
discuss the ideas, just list them.
 Brainstorm ways to avoid wasting the drug and record the ideas on the
“Pharm P2” page. Again, state an idea or pass until no more ideas surface,
without discussion.
 If your group has time, pick a preferred Pharm P2 approach for this situation.
 Leave the charts here –composite results will be sent out to the WH2E
listserv.
DISCLAIMER: I am not a pharmacist. I have never worked in a healthcare
facility. If these examples don’t make sense, are too broad or too narrow, change
them. If necessary, make up some “facts” and go on with the exercise. Record
any changes you make so your answers make sense to future readers.
To generate ideas, consider the following factors and questions:
 The individual’s motivation -- what makes them want to do the wrong thing or
not want to do the right thing?
 The individual’s ability – why can’t they prevent wasting? What about them
personally makes it easy to waste drugs?
 Social issues – what do people around this individual do that enables wasting
or disables pollution prevention? Consider both motivation and ability here
too, for coworkers and superiors.
 Environmental – what is it in the physical surroundings that enables wasting
or disables pollution prevention?
 Systems -- What systems, policies, contracts, union rules, regulations, etc.,
enable wasting? What prevent or disable waste minimization?
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Group 1: Sample medications. (Source: case study on MnTAP website)
A small clinic generates pharmaceutical waste from expired, unused, or
contaminated medications, products, drugs, and vaccines. The most prominent
source of pharmaceutical waste at this clinic is from expired sample medications
supplied by pharmaceutical representatives. Physicians then offer the samples to
patients as a free trial. The clinic staff members attempt to maintain log books to
document sample inventory, usage, expiration, and recalls. However, the logs
are not always accurate; some representatives are unaware of the log book and
physicians rarely have time to record each sample they distribute.
The samples supplied to the clinic by pharmaceutical companies often go unused
and expire. Once a month, a member of the clinic staff sorts each of the roughly
100 different types of samples to find those that expired. All of the expired
samples must then be documented and properly disposed of. When samples
become waste, regulations may require they be disposed of as hazardous waste.
Why are these sample medications becoming waste?
What might this clinic do to minimize or eliminate sample waste?
Group 2: Crash boxes. (source: MnTAP case study, Appendix C, PGH 10 step guide)
A large urban hospital examined the pharmaceuticals being wasted. Last year,
the hospital returned over 900 different outdated pharmaceuticals for credit, most
in multiple quantities, through the reverse distribution process. The total cost to
purchase was $150,000. Only 202 items were credited for a total of $75,000.
Crash boxes, similar to crash carts, were found to be a significant source of
pharmaceutical waste. These boxes contain emergency medicine needed to
revive someone under cardiac arrest. Drugs that are not used by their expiration
date are wasted. When this occurred in the past, the pharmacy exchanged the
box and updated all the drugs so they are good for about one year. Nearly
outdated drugs were sent for reverse distribution. Many of the drugs found in the
boxes are regularly used in other locations in the hospital.
Here are some examples of drugs wasted from the crash boxes:
 A specialty Epinephrine Intracardiac Syringe that was rarely used. It expired
or was returned 98% of the time.
 Glutose Gel in a 45 gram dosage type, much of which was wasted. In most
cases, a 30 gram dose of glucose is used.
 Name brand nitroglycerin bottle of 100-count size.
Why are the pharmaceuticals in the crash boxes being wasted?
What can this hospital do to eliminate or minimize pharmaceutical waste from its
crash boxes?
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Group 3: Pharmacy (source: MnTAP case study, Appendix C, PGH 10 step guide)
In a small rural hospital, a staff pharmacist noticed many drugs on site were
outdated and the facility was stocking too many extra medications. This hospital
was checking for outdated drugs every other month, stock was not rotated
regularly and par usage reports were not available.
Looking closely into quantities ordered and costs, the pharmacist realized that
chemotherapy drugs were the largest expense for the facility. They were being
ordered monthly and in one month, the facility spent over $90,000. Because of
the long holding time for some of the chemotherapeutics, they were outdating on
the shelf. Some chemotherapy drugs were very high cost and came in multiple
strengths.
Why are so many chemotherapy drugs in this hospital being wasted?
What can this hospital do to minimize wasted chemotherapy drugs?
Group 4: Bedside wasting. (Source: Russell Mankes, Albany Medical Center, Albany
New York. Personal communication. Percentages were altered for the sake of the exercise)
An urban hospital looked into the amounts of controlled substances that are
being wasted after being dispensed. The environmental safety director reviewed
weekly print-outs of all drugs dispensed, wasted, returned from the facility’s drug
dispensing machines and compared that to the drugs found in the
pharmaceutical waste containers from that area for the same time period.
An average of 5% of controlled substances dispensed were being wasted at the
patient’s bedside.
 Acetaminophen and codeine (30% of what is dispensed).
 hydromorphone (27%)
 midazolam (21%)
 morphine (2%)
 hydrocodone and acetaminophen (1%)
An additional 7% of dispensed controlled substances were found in the facility’s
pharmaceutical waste containers.
 Testosterone (35% of what is dispensed)
 ketamine (6%)
 fentanyl patches(2%)
 morphine (0.4%)
 midazolam (0.3%)
Why are dispensed controlled substances being wasted in this facility?
What can this hospital do to prevent or minimize wasting controlled substances?
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Group 5 OR cases (for the conference callers) (Source: Russell Mankes, Albany
Medical Center, Albany New York. Personal communication.) See also the MnTAP website for
another example of waste minimization of OR supplies picked before surgeries.
The director in Group 4’s facility also found that propofol was commonly wasted
in large amounts in the operating rooms. Surgeons often ordered the 50 and 10
ml sizes to be “picked” before surgery. The 10 ml size was often unused and the
50 ml size was usually partially used. A 20 ml size of propofol is available.
Why is this drug being wasted? Think of every possible reason, all the way up
and down the supply chain.
What can be done to minimize or avoid wasting this drug?
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“WASTING” IDEAS
Group number _____
Who is your recorder? _______________
Recorder: please record all ideas using complete sentences, such as “the nurse is too busy” or
“there is no other container” or “it takes too long to order from our supplier” so we can compile
your group’s ideas later without inadvertently distorting them.
Who is your presenter? ________________ (in case there is time to present)
Starting with your recorder, go around the circle, as quickly as possible, stating
possible reasons why this drug or type of drug is being wasted or would be easy
to waste. Try to state your idea in one complete sentence.
Each person should either state a reason or pass, and keep going around the
circle until everyone passes in a row. Don’t judge or discuss the ideas at this
point. The idea is to think of as many reasons as possible.
Did your group change the “facts” of this situation, or change the question
in any way? If so, write down those changes here so your answers make
sense to people in the future.
Why is this drug being wasted? What enables wasting or disables waste
minimization? See the factors/questions at the bottom of page 3 to help
generate ideas.
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PHARM P2 IDEAS
Group number _____
Recorder _______________
Presenter ________________
Brainstorm ways to minimize wasting this drug or type of drug. Again, each
person will state an idea or pass until no more ideas surface, without discussion.
Refer to the questions at the bottom of page 3.
Write down all ideas. While it may seem silly or unworkable in this situation, you
may help generate a solution for someone else who reads the list in the future.
What can people do in this situation to minimize or prevent pharmaceutical
waste? If you have time, star the solutions your group would actually
implement.
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