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ISBN : 978-974-244-375-7
:

:
88/24 11000
02 590 7289, 02 591 8278
02 590 7287
ipcs_fda@fda.moph.go.th
http://ipcs.fda.moph.go.th/csnetNEW/
1 : 2559
:

.. .. 2554

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21

3 (1) /

(2) (3)

2559

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IV

III
IV
1

1
/ 2
(Pharmaceutical waste)

(I) 5
(II) 9

13

14

29

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()

2

(Laboratory waste)

33

3

(Heavy metal in medical device)

51

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34
40
49
50

51
52
52
53
54
62

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//
/ (Pharmaceutical waste)

(Laboratory waste)

(Heavy metal in medical device)

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/
(Pharmaceutical waste)

4000
10
71
600

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25

WHO (2012)
25

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U.S. FDA
Pregnancy Category X

Avoid/Reduce
Reuse
Recycle
Waste to
energy
Disposal
of waste

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/

(Waste Minimization)

/

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/

2

1.
2.

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(I)
/

(antibiotic) (antiviral drug)

(hormone)

(endocrine disruptor)
1

(toxic to reproductive system)

(pregnancy category X)

(chemotherapy)

(immunosuppressive)

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1200 C (
)
(lined hazardous
waste landfill)
Lined Hazardous Waste Landfill

>1200 C

Tuberculosis (BCG)

Oral polio vaccine (OPV) Rotavirus

Measles
Yellow fever

Landfill

850 C
( )
(Landfill
)

> 850 C

850 C (
)
(witnessed destruction)

> 850 C

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Landfill

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4

850 C ( )

Landfill

> 850 C

1 1

Water Treatment Plant

Hazardous
Waste Incinerator
> 1200

Autoclave

Medical Waste
Incinerator
> 850

1 /
( Presentation Pharmaceutical waste management Massoomi, 2011)

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1 /

* /

()

()

()

()

1000-1200 o C 1000-1200 o C 800-1000 o C 800-1000 o C

800-1000 o C

* P-list, U-list, D-list The Resource Conservation and

Recovery Act (RCRA) U.S. EPA hazardous pharmaceutical waste U.S.CDC /

NIOSH 3

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(II)

/

. .

(1)

(2)

()

(
)

() ()

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10

(II) ()

(.)

(chemotherapy)
(antibiotic) (antiviral drug)
(hormone)

(endrocrine disruptor)
(toxic to reproductive system)
(pregnancy category X)
(immunosuppressive)

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2
2 /

- /

- ()

800-1000 o C

( )

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2 /
( )

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13

Charlotte A. Smith (2002). Managing Pharmaceutical Waste- What pharmacists should know.
Journal of the Pharmacy Society of Wisconsin. Madison, WI: Pharmacy Society of Wisconsin.
FDA (Food and Drug Administration) (2011). How to Dispose of Unused Medicines.
FDA Consumer Health Information. Washington, D.C.: FDA.

NIOSH (National Institute for Occupational Safety and Health) (2004). NIOSH Alert:
Preventing Occupational Exposures to Antineoplastic and Other Hazardous Drugs in Health
Care Settings. Cincinnati, OH: NIOSH.
NIOSH (2012). NIOSH List of Antineoplastic and Other Hazardous Drug in Healthcare
Setting. Cincinnati, OH: NIOSH.
NIOSH (2014). NIOSH List of Antineoplastic and Other Hazardous Drug in Healthcare
Setting (update). Cincinnati, OH: NIOSH.
Practice Greenhealth and U.S. EPA (2008). Managing Pharmaceutical Waste : A 10 Step
Blueprint for Healthcare Facilities in the United States. Reston, Virginia: Practice Greenhealth.
U.S. EPA (United States Environmental Protection Agency) (1976). The Resource Conservation
and Recovery Act (RCRA).

FDA (2013). Medicines Recommended for Disposal by Flushing. Washington, D.C.: FDA.

UNEP (United Nations Environment Programme) and WHO (2013). State of the Science of
Endocrine Disrupting Chemicals 2012 Summary for Decision-Makers. Geneva: UNEP and WHO.

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/
(Pharmaceutical Waste)

U.S. Environmental Protection Agency (EPA),

U.S. Centers for Disease Control and Prevention (CDC)/National Institute of
Occupational Safety and Health (NIOSH)
U.S. Drug Enforcement Administration (DEA)
/
1. The Resource Conservation and Recovery Act (RCRA)/U.S. EPA
/ 3
1.1 P-Listed Waste (Acutely Toxic)
oral LD50 50 mg/kg BW.
Hazardous Waste
1.2 U-Listed Waste (Toxic)
3% (w/w) Hazardous Waste
1.3 D-Listed Waste P-Listed Waste U-Listed Waste

1
(1) (Ignitability) alcohol 24% ,
( colloid) (Flash point) 140 F 60 C,
Silver nitrate, Potassium permanganate
Aerosol (propellant)
(2) (Corrosivity) (pH) 2 ()
12.5 ()
glacial acetic acid, sodium hydroxide
(3) (Reactivity)
/ Nitroglycerin
(4) (Toxicity) EPA

Oral LD50
50

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15
2. U.S.CDC/ NIOSH /
hazardous pharmaceutical waste
2.1 (Chemotherapy) 2
2.1.1 Trace chemotherapy waste
3%
2.1.2 Hazardous chemotherapy waste
3% hazardous chemotherapy waste
2.2 (Endocrine disruptor)
estrogen derivatives
2.3 (Pregnancy category X)
2.4 (Antibiotic)
2.5 oral LD50 50 mg/kg BW.
2.6 U.S. National Institute of Occupational Safety and Health (NIOSH) CDC
hazardous drug (chemotherapy) (antiviral drug)
(hormone) (immunosuppressive)
- (carcinogenicity)
- (genotoxicity)
- (teratogenicity)/ (developmental toxicity)
- (reproductive toxicity)
- (organ toxicity at low doses)
- hazardous drug
NIOSH
http://www.cdc.gov/niosh/topics/hazdrug/default.html
1 2
1200 C
(lined hazardous waste landfill)
3. Controlled substance
U.S. Drug Enforcement Administration (DEA)
(witnessed destruction)
3
850 C

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16

3 The Resource Conservation and

Recovery Act (RCRA)/ U.S. EPA U.S.NIOSH/CDC
(
1200 C)

EPA

(Chemotherapy)

NIOSH Preg.
X

Abiraterone acetate

Antineoplastic

Aldesleukin

Antineoplastic

Altretamine
Amsacrine
Anastrozole
Arsenic trioxide

Antineoplastic
Antineoplastic
Antineoplastic
Antineoplastic

Asparaginase
Azacitidine

Antineoplastic
Antineoplastic

Bendamustine HCI
Antineoplastic
Bevacizumab Antineoplastic

(Monoclonal antibody)

Bexarotene

Antineoplastic

Bicalutamide
Antineoplastic
Bleomycin
Antineoplastic
Bortezomib
Antineoplastic
Brentuximab vedotin Antineoplastic

(Antibody-drug conjugate)

Busulfan
Cabazitaxel

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Antineoplastic
Antineoplastic

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3 U.S. EPA U.S.NIOSH/CDC

(
1200 C) ()

EPA

NIOSH Preg.
X

Capecitabine

Antineoplastic

Carboplatin

Antineoplastic

Carmustine

Antineoplastic

Chlorambucil
Cisplatin
Cladribine
Clofarabine

Antineoplastic
Antineoplastic
Antineoplastic
Antineoplastic

Crizotinib
Cyclophosphamide

Antineoplastic
Antineoplastic

Cytarabine
Dacarbazine
Dactinomycin

Antineoplastic
Antineoplastic
Antineoplastic

Dasatinib
Daunorubicin HCI
Decitabine
Degarelix
Denileukin
Docetaxel
Doxorubicin
Epirubicin

Antineoplastic
Antineoplastic
Antineoplastic
Antineoplastic
Antineoplastic
Antineoplastic
Antineoplastic
Antineoplastic

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3 U.S. EPA U.S.NIOSH/CDC

(
1200 C) ()

EPA

NIOSH Preg.
X

Eribulin mesylate

Antineoplastic

Erlotinib

Antineoplastic

Estramustine phosphate

Antineoplastic

Etoposide
Everolimus
Exemestane
Floxuridine

Antineoplastic
Antineoplastic
Antineoplastic
Antineoplastic

Fludarabine
Fluorouracil

Antineoplastic
Antineoplastic

Flutamide
Fulvestrant
Gemcitabine

Antineoplastic
Antineoplastic
Antineoplastic

Gemtuzumab ozogamicin
Goserelin
Hydroxyurea
Idarubicin
Ifosfamide
Imatinib mesylate
Irinotecan HCI
Ixabepilone

Antineoplastic
Antineoplastic
Antineoplastic
Antineoplastic
Antineoplastic
Antineoplastic
Antineoplastic
Antineoplastic

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3 U.S. EPA U.S.NIOSH/CDC

(
1200 C) ()

EPA

NIOSH Preg.
X

Letrozole

Antineoplastic

Leuprolide acetate

Antineoplastic

Lomustine

Antineoplastic

Mechlorethamine
Megestrol
Melphalan
Mercaptopurine

Antineoplastic
Antineoplastic
Antineoplastic
Antineoplastic

Methotrexate
Mitomycin

Antineoplastic
Antineoplastic

Mitotane
Mitoxantrone HCI
Nelarabine

Antineoplastic
Antineoplastic
Antineoplastic

Nilotinib
Nilutamide
Oxaliplatin
Paclitaxel
Pazopanib HCI
Pegaspargase
Pemetrexed
Pentostatin

Antineoplastic
Antineoplastic
Antineoplastic
Antineoplastic
Antineoplastic
Antineoplastic
Antineoplastic
Antineoplastic

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3 U.S. EPA U.S.NIOSH/CDC

(
1200 C) ()

EPA

NIOSH Preg.
X

Pipobroman

Antineoplastic

Pralatrexate

Antineoplastic

Procarbazine

Antineoplastic

Romidepsin
Sorafenib
Streptozocin
Sunitinib malate

Antineoplastic
Antineoplastic
Antineoplastic
Antineoplastic

Tamoxifen
Temozolomide

Antineoplastic
Antineoplastic

Temsirolimus
Teniposide
Testolactone

Antineoplastic
Antineoplastic
Antineoplastic

Thioguanine
Thiotepa
Topotecan
Toremifene citrate
Triptorelin
Uracil mustard
Valrubicin
Vandetanib

Antineoplastic
Antineoplastic
Antineoplastic
Antineoplastic
Antineoplastic
Antineoplastic

Antineoplastic
Antineoplastic

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3 U.S. EPA U.S.NIOSH/CDC

(
1200 C) ()

EPA

NIOSH Preg.
X

Vemurafenib

Antineoplastic

Vinblastine sulfate

Antineoplastic

Vincristine sulfate

Antineoplastic

Vinorelbine tartrate
Vorinostat

Antineoplastic
Antineoplastic

Chloramphenicol

Antibiotic

Televancin
Tetracycline HCI

Bactericidal
Antibiotic

(Antibiotic)

(Antiviral)
Abacavir
Cidofovir
Entecavir
Ganciclovir
Nevirapine
Ribavirin
Trifluridine
Valganciclovir
Vidarabine
Zidovudine

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Antiviral
Antiviral
Antiviral
Antiviral
Antiviral
Antiviral
Antiviral
Antiviral
Antiviral
Antiretroviral

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3 U.S. EPA U.S.NIOSH/CDC

(
1200 C) ()

EPA

NIOSH Preg.
X

(Antifungal)
Fluconazole

Antifungal

Voriconazole

Antifungal

(Antiprotozoal)
Pentamidine isethionate

Antiprotozoal

(Hormone)
Cetrorelix acetate
Gonadotropin-releasing
hormone antagonist

Choriogonadotropin alfa
Diethylstilbestrol (DES)

Estradiol
Estrogen-progestin combinations
Estrogen, conjugated

Gonadotropins
Synthetic Estrogen
Estrogen
Contraceptive
Estrogen

Ganirelix acetate
Gonadotropin-releasing
hormone antagonist

Gonadotropin, chorionic
Medroxyprogesterone acetate

Estrogens, esterified
Estrone
Estropipate
Fluoxymesterone

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Estrogen
Estrogen
Estrogen
Androgen

Gonadotropin
Progestin

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3 U.S. EPA U.S.NIOSH/CDC

(
1200 C) ()

EPA

NIOSH Preg.
X

Gonadotropin

Androgen

Gonadotropin

Progesterone
Progestins
Progestins
Contraceptive
Propylthiouracil
Antithyroid
Raloxifene Estrogen

agonist-antagonist

Tesamorelin acetate
Testosterone

Somatropin, GRF analog

Androgen

Contraceptive

Menotropins
Methyltestosterone
Nafarelin

Ulipristal acetate

Alefacept

Immunosuppressant

Azathioprine
Immunosuppressant

Cyclosporin
Immunosuppressant

Fingolimod
Biological response

modulator
Leflunomide Antirheumatic

(immunosuppressant)
Lenalidomide
Biologic response

modifier

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3 U.S. EPA U.S.NIOSH/CDC

(
1200 C) ()

EPA

NIOSH Preg.
X

Mycophenolate mofetil

Immunosuppressant

Mycophenolic acid

Immunosuppressant

Sirolimus

Immunosuppressant

Tacrolimus
Immunosuppressant
Thalidomide
Biologic response
modifier

(Anticonvulsant)
Carbamazepine
Clonazepam
Ezogabine
Oxcarbazepine
Topiramate
Valproic acid/divalproex Na
Vigabatrin
Zonisamide

Anticonvulsant

Anticonvulsant, sedative
Anticonvulsant

Anticonavulsant
Anticonvulsant
Anticonvulsant
Anticonvulsant
Anticonvulsant

/ (Chelator)
Deferiprone
FE chelator
Dexrazoxane
Chelator
Pentetate calcium Chelating agent
trisodium(Ca-DTPA)
(for removing radioactives)

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3 U.S. EPA U.S.NIOSH/CDC

(
1200 C) ()

EPA

NIOSH Preg.
X

Physostigmine

Acholinergenic

Physostigmine salicylate

Acholinergenic

Resorcinol
Dronedarone HCI
Warfarin
Paroxetine

Acne, dandruff treatment

Antiarrhythmic
Anticoagulant

Antidepressant

Antidiabetic
Antigout

Ambrisentan

Antihypertensive,
Vasodilating agent

Bosentan

Antihypertensive,

Vasodilating agent

Liraglutide recombinant
Colchicine

Phenoxybenzamine HCl
Antihypertensive,

Non-selective
alpha-adrenergic
blocking agent

Reserpine
Antihypertensive,

antipsychotic
Rasagiline mesylate
Risperidone

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Antiparkinson
Antipsychotic

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3 U.S. EPA U.S.NIOSH/CDC

(
1200 C) ()

Ziprasidone HCI

EPA

Antipsychotic

Mercury Antiseptic
(mercurochrome)

Device (thermometer,

sphygmomanometer)
Preservative

(thimerosal in vaccine)

NIOSH Preg.
X

Phenol
Antiseptic, anesthetic,
antipruritic
Phentermine
Appetite suppressant

(Controlled substance)

Zoledronic acid
Bone resorption inhibitor
Icatibant Bradykinin B 2

receptor antagonist

Palifermin

Cell stimulants
and proliferant

Tretinoin Cell stimulants

and proliferant

Chloral hydrate
(Controlled substance)

Cough syrup,
sleeping pill

Diuretic

Spironolactone
Apomorphine

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Dopamine agonist

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3 U.S. EPA U.S.NIOSH/CDC

(
1200 C) ()

EPA

Dutasteride Drug for bladder

& prostate disorders
Finasteride Drug for bladder

& prostate disorders
Epinephrine base Emergency allergy kit,

cardiac arrest, glaucoma,
eye surgery
Cabergoline Ergot-derivative

dopamine receptor
agonist

NIOSH Preg.
X

Plerixafor
Hematopoietic agent

Cadmium
Multiple mineral

preparations
M-cresol
Preservative in human

insulin
Dinoprostrone
Oxytocic

Ergonovine/methylergonovine
Oxytocic

Mifepristone
Oxytocin
Barium sulfate

Oxytocic
Oxytocic
Radiopaque agent

Lindane
Hexachlorophene

Scabicide
Skin disinfectant

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3 U.S. EPA U.S.NIOSH/CDC

(
1200 C) ()

EPA

Dexmedetomidine
Sedative

Paraldehyde
Sedative

(Controlled substance)
Selenium
Shampoo (anti-dandruff)
Multiple mineral
preparations

NIOSH Preg.
X

Skin and mucous

membrane agent

Podophyllum resin
Skin and mucous

membrane agent
(Cytotoxic)

Podofilox
Skin and mucous

membrane agent
(antimitotic)

Alitretinoin

Nicotine

Smoking cessation

Misoprostol
Stomach ulcers
treatment
Trichloromonofluoromethane

Topical anesthetic

Silver (> 5 mg/l)

Topical antimicrobial

( Silver sulfadiazine cream)

Bacillus Calmette-Guerin (BCG)
Vaccine

Acitretin

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Vitamin A

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(Laboratory waste)

CI

(solvent)

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(Safety Data Sheet : SDS)

()

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34

1
(SDS)

4
4
2 //
Polypropylene (PP) Polyethylene (PE)

Hydrofluoric acid


( ether, dichloromethane,
)
High density polyethylene (HDPE)

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35

1
parafilm
(secondary containment)

2


3

3 4

(secondary containment)

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4



5

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38
6 /

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39

ethyl ether, hexane,

acetone

hydrochloric acid, sodium hydroxide

1 M (1 Molar
1 /)

Hydrogen peroxide
Copper, chromium, iron 5

(LD50 > 500 mg/kg)

(

)
(LD50 < 500 mg/kg)
1 ()
Ethidium Bromide,
Xylene

LD50 50

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40

5
()

Acetic acid

Chromic acid, nitric acid, hydroxyl compounds,

ethylene glycol, perchloric acid, peroxides, permanganates

Acetone

Concentrated nitric and sulfuric acid mixtures

Acetylene

Chlorine, bromine, copper, fluorine, silver, mercury

Alkali and alkaline

earth metals (lithium,
sodium, potassium)

Water, carbon tetrachloride other chlorinated

hydrocarbons, carbon dioxide, halogens, powdered
metals ( aluminum or magnesium)
Mercury ( thermometer, manometers), chlorine,
calcium hypochlorite, iodine, bromine, hydrofluoric acid
(anhydrous)
Acids, powdered metals, flammable liquids, chlorates,
nitrates, sulfur, finely divided organic or combustible
materials
Nitric acid, hydrogen peroxide

Ammonia (anhydrous)
Ammonium nitrate
Aniline
Arsenical materials
Azides

Reducing agents

Bromine

Chlorine

Calcium oxide

Water

Carbon (activated)
Carbon tetrachloride

Calcium hypochlorite, all oxidizing agents

Sodium, Chlorates, Ammonium salts, acids, powdered
metals, sulfur, finely divided organic or combustible
materials

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Acids

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41

5
() ()

Chlorine

Ammonia, acetylene, butadiene, butane, methane,

propane ( other petroleum gases), hydrogen,
sodium carbide, benzene, finely divided metals,
turpentine

Chlorine dioxide
Chromic acid and
chromium
Copper
Cumene hydroperoxide
Cyanides
Flammable liquids

Ammonia, methane, phosphine, hydrogen sulfide

Fluorine
Hydrocarbons
( butane, propane,
benzene)
Hydrocyanic acid
Hydrofluoric acid
(anhydrous)
Hydrogen peroxide

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Acetic acid, naphthalene, camphor, glycerol, alcohol,

flammable liquids
Acetylene, hydrogen peroxide
Acids (organic inorganic)
Acids
Ammonium nitrate, chromatic acid, hydrogen peroxide,
nitric acid, sodium peroxide, halogens

Fluorine, chlorine, bromine, chromic acid,

sodium peroxide
Nitric acid, alkali
Ammonia (aqueous anhydrous)
Copper, chromium, iron, most metals & their salts,
alcohols, acetone, organic materials, aniline,
nitromethane, combustible materials

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42

5
() ()

Hydrogen sulfide
Hypochlorites
Iodine
Mercury
Nitrates
Nitric acid (concentrated)
Nitrites
Nitroparaffins
Oxalic acid
Oxygen
Perchloric acid
Peroxides, organic
Phosphorus (white)
Phosphorus pentoxide
Potassium
Potassium chlorate
Potassium perchlorate
Potassium permanganate
Selenides
Silver

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Fuming nitric acid, oxidizing gases
Acids, activated carbon
Acetylene, ammonia (aqueous anhydrous), hydrogen
Acetylene, fulminic acid, ammonia
Sulfuric acid
Acetic acid, aniline, chromic acid, hydrocyanic acid,
hydrogen sulfide, flammable liquids, flammable gases,
copper, brass, any heavy metals
Potassium cyanide sodium cyanide.
Inorganic bases, amines
Silver, mercury
Oils, grease, hydrogen, flammable: liquids, solids, gases
Acetic anhydride, bismuth and its alloys, alcohol, paper,
wood, grease, oils
Acids (organic mineral)

Air, oxygen, alkalis, reducing agents
Water
Carbon tetrachloride, carbon dioxide, water
Sulfuric and other acids
Sulfuric, other acids chlorates
Glycerol, ethylene glycol, benzaldehyde, sulfuric acid
Reducing agents
Acetylene, oxalic acid, tartaric acid, ammonium compounds,
fulminic acid
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43

5
() ()

Sodium

Carbon tetrachloride, carbon dioxide, water

Sodium chlorate

Acids, ammonium salts, oxidizable materials, sulfur

Sodium nitrite

Ammonium nitrate and other ammonium salts

Sodium peroxide

Ethyl or methyl alcohol, glacial acetic acid, acetic

anhydride, benzaldehyde, carbon disulfide, glycerin,
ethylene glycol, ethyl acetate, methyl acetate,
furfural
Acids

Sulfides
Sulfuric acid

Potassium chlorate, potassium perchlorate, potassium

permanganate ( light metals
sodium, lithium)

Tellurides

Reducing agents

Water ()

Acetyl chloride, alkali and alkaline earth metals,

their hydrides and oxides, barium peroxide, carbides,
chromic acid, phosphorous oxychloride, phosphorous
pentachloride, phosphorous pentoxide, sulfuric acid,
sulfur trioxide

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44

1200 C
( )
(lined hazardous waste landfill)

Lined Hazardous Waste Landfill

>1200 C

Barium
Sulfate, Iodine Contrast

6
SDS

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45

Personal Protective Equipment
(PPE) /

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46

A
B

A1 A2 A3 A4 B1 B2 B3

Acetic acid
Ammonia

Barium sulfate

Chlorhexidine
gluconate
70% Ethanol
Fixer + Developer

x-ray
10 % Formalin
buffer 3.7%
Formaldehyde
Glutaradehyde
(working solution :
)
Iodophor
(Iodine + HCl)
Hydrochloric acid
3-5 % Hydrogen
Peroxide

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Fixer

(Ag)

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47

6
()

A
B

A1 A2 A3 A4 B1 B2 B3

Iodine contrast

Mercury

Methanol

Lysol Cresol
(working solution)
Povidone Iodine

Solution
Sodalime

Sodium

hypochlorite
(working solution)
Sodium hydroxide
Sevoflurane

Trichloroacetic
acid
Toluene

Xylene

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48

6
()

A
B

A1 A2 A3 A4 B1 B2 B3

A1 1 /

A2 1 /

A3

A4 9 25% 1
24
B1 HDPE

B2 HDPE

B3 recycle

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49

,
(2547). .
: .

, ,
(2549).
(Chemical Safety for Medical Laboratory). : .

National Research Council (1995). Prudent practices in the laboratory. Washington,
D.C. : National Academies Press.

University of Cambridge, Occupational Health and Safety Service (2012). Chemical
Safety Guidance: Disposal of Chemical and Laboratory Waste Including the Zero to Drains
Policy. Cambridge: University of Cambridge.

E-Book FULL.indd 49

, ,
(2555).
. : .

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50

1.
2
(flash point) 93.4 C
24 benzene, toluene, xylene, acetone kerosene
sodium metal
phosphorus
carbon, sulfur, aluminum metal
2.
sulfuric acid,
hydrochloric acid, nitric acid
3.

alkyl magnesium
halides n-butyllithium
sodium metal

potassium chlorate aluminum powder
calcium carbide sodium amide
potassium cyanide ferrous sulfide
ammonium
nitrate nitrocellulose
4.

Parathion-methyl
Benzene, Chloroform, Formaldehyde, Ethylene oxide
Ethidium bromide
Lead, Toluene

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51

(Heavy metal in medical device)

1 /







2
(
)

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52

(Heavy metal in medical device)
2

(alloy)


(trituration)
2 alloy tablet


Precapsulated alloy

3.1
( )
()

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53

3.2

3.3

MRI

American Dental Association (2007). Brochure: Best Management Practice for

Amalgam Waste. Chicago, IL: American Dental Association.

, , (2551).
. : .

, (2556). .
: .

, , ,

(2558). .
: .

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54

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55

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..

..

17

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