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Guideline for the safe prescribing, handling and
Administration of Chemotherapy for Adults in the Treatment of
malignant disease 1
This guidance does not override the individual responsibility of health professionals to make
appropriate decision according to the circumstances of the individual patient in consultation
with the patient and /or carer. Health care professionals must be prepared to justify any
deviation from this guidance.
Introduction
This document has been developed to set out the guidelines for the prescribing, handling and
administration of chemotherapy in adult patients being treated for malignant disease. It is
intended that this document will reflect the guidelines of the previous cancer networks with
which Worcestershire Acute Hospitals NHS Trust was affiliated with.
This guideline is for use by the following staff groups :
All personnel utilising this guideline should have undertaken the appropriate training as
designated by their professional discipline and detailed in their educational portfolio.
Lead Clinician(s)
Sue Sharp
Chemotherapy/Radiotherapy project nurse
Approved by Medicines Safety Committee on:
7th May 2014
Approved by Oncology/Haematology
Directorate meeting on:
19th May 2014
This guideline should not be used after end of:
19th May 2016
Guideline for the safe prescribing, handling and administration of chemotherapy for adults in
the treatment of malignant disease
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Key amendments to this guideline
Date
Nov 2005
Dec 2010
July 2011
March 2012
26.03.14
April 2014
August 2016
Amendment
Approved by Clinical Effectiveness Committee
Revised by chemotherapy project nurse
Revised by chemotherapy project nurse
Revised by chemotherapy project nurse to reflect
chemotherapy peer review measures 2011
Approved by cancer services and clinical haematology
directorate meeting
Revised by chemotherapy project nurse to reflect
changes in network structure and local protocols
Document extended for 12 months as per TMC paper
approved on 22nd July 2015
Approved by:
Sue Sharp
Sue Sharp
Sue Sharp
Sue Sharp
TMC
1
“Where chemotherapy is cited this includes chemotherapy, monoclonal antibodies, and all medications used in the
treatment of Oncology/Haematology diagnoses. This is not a guideline for practice in non-malignant disease although
some of the principles may be the same.”
Guideline for the safe prescribing, handling and administration of chemotherapy for adults in
the treatment of malignant disease
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WAHT-NUR-064
It is the responsibility of every individual to ensure this is the latest version as published on the Trust Intranet
Guideline for the safe prescribing, handling and administration of
chemotherapy for adults in the treatment of malignant disease
Introduction
This document has been developed to set out the guidelines for the prescribing, handling and
administration of chemotherapy in adult patients being treated for malignant disease. It is intended
that this document will reflect the guidelines of the previous cancer networks with which
Worcestershire Acute Hospitals NHS Trust was affiliated with.
The utilisation of chemotherapy in the management of malignancy is potently hazardous to both
the health care personnel involved in the preparation and administration of the chemotherapy in
addition to the patients receiving them.
The aim of this guideline is to maximise patient and staff safety throughout the process of the
preparation and administration of chemotherapy.
The scope of this document is intended for the following patient groups.
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Patients receiving chemotherapy for the treatment of malignant disease
Patients over the age of 16 being cared for in adult services.
This document does not cover
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Intrathecal chemotherapy
Intracavity chemotherapy e.g. intrapleural, intravesical
Separate documents should be developed for utilisation within the Trust
The administration of chemotherapy for non-malignant disease
Whilst stating that this document does not cover non-malignant disease the principles are
similar and this document should be utilised to ensure that where consistencies exist this is
reflected in documents relating to the administration of chemotherapy in the non-malignant
setting.
Paediatric patients under the age of 16.
Worcestershire Acute Hospitals NHS Trust is a Level 1 provider for the Birmingham
Children’s hospital with inpatient and clinic services based at Worcester. Services are
delivered conforming to the shared care service measures as outlined in the Improving
Outcomes Guidance for Children and Young People and the service follows the
Birmingham Children’s Hospital policies.
Competencies Required
All personnel utilising this guideline should have undertaken the appropriate training as
designated by their professional discipline and detailed in their educational portfolio.
Staff involved in the care of patients receiving chemotherapy should have their competency
assessed as being proficient and documented in their individual educational portfolio for the areas
of practice that they are involved in before undertaking independent activity.
Each member of staff must have an educational portfolio demonstrating the competencies
acquired for the area/areas of practice they are involved in. The frequency of assessment of
competencies is as detailed in the educational portfolio or more frequently if a concern/incident is
raised regarding the ability of an individual to undertake the skill required
Guideline for the safe prescribing, handling and administration of chemotherapy for adults in
the treatment of malignant disease
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The prescribing, verification, checking and administration of cytotoxics should be restricted to
statutorily registered health care professionals in medicine, nursing and pharmacy
Each department must have a register of staff and their areas of competence. (Manual for Cancer
Services: Chemotherapy measures 2014.)
The assessment of competency will be undertaken by an authorised assessor of the clinical
chemotherapy service. At WAHT in order to be designated as an assessor of competency for
chemotherapy the following is required
 A recognised teaching and assessing qualification
 Be competent in the area being assessed
 Have administered chemotherapy for more than 18 months.
For other areas of competency in order to be designated as an assessor additional qualifications
may be required.
Details of Guideline
1. Facilities
Systemic chemotherapy for the treatment of cancer patients over the age of 16 being cared for in
adult services will only be administered within the environments, which have been designated for
this purpose across the acute trust as stated in Table 1.
Table 1
HOSPITAL
SUITE
SPECIALITIES
Worcestershire Royal
Rowan suite
Oncology/haematology
Worcestershire Royal
Laurel 3 (in-patient)
Haematology
Alexandra
Garden suite
Oncology/haematology
KidderminsterTreatment centre
Millbrook suite
Oncology/haematology
Suite manager will ensure facilities meet standards required in this document or formally
report to lead nurse any deficits identified
The administration of chemotherapy for malignant disease other than in dedicated facilities should
only be undertaken where a patient is not clinically stable enough to be transferred to an
appropriate environment. In this situation the clinician responsible for the patient’s care must
determine that it would be inappropriate to delay the patient’s treatment until the patient is fit to be
transferred. The decision to treat a patient in an area which is not designated for this purpose
must be documented in the patient’s notes by the responsible clinician.
Designated areas should have a separate area for the tasks involved in the preparation and
delivery of chemotherapy.
These areas must have separate and designated areas for the temporary storage of
chemotherapy drugs which have been dispensed from pharmacy.
Chemotherapy drugs which require refrigeration that have been dispensed from pharmacy and
need temporary storage within the chemotherapy unit must be stored in a separate and
designated fridge.
Within the designated areas there will be guideline documents (or electronic access to) and the
equipment required for the management of the following emergencies: Guideline for the safe prescribing, handling and administration of chemotherapy for adults in
the treatment of malignant disease
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Anaphylaxis
Chemotherapy Extravasation
Cardiac Arrest
Spillage of Chemotherapy
The agreed lists of treatment protocols of the clinical chemotherapy service will be available (or
have electronic access to) within the individual chemotherapy units.
These areas will have available the mechanical drug delivery devices required for the safe
administration of chemotherapy.
These devices will have annual maintenance checks or more often if deemed appropriate.
These devices will only be utilised by competent practitioners who have undergone
Worcestershire Acute Hospitals Trust approved training in use of the mechanical devices which
adheres to the local Trust policy “ Medical Devices Policy including Education and Training”
(WAHT-CG-022).
The practitioner will have responsibility for reporting faults or lack of consistent performance of a
mechanical delivery device.
2. Out of Hours Initiation and Administration of Chemotherapy.
It is recognised that the initiation and as much as possible administration of outpatient
chemotherapy should be during normal working hours of Monday – Friday 8-6pm. The risk of
accidents is increased when complex regimens are given outside normal working hours when
minimal specialist staff are available.
However the administration of in-patient chemotherapy can be continued outside working hours
when appropriately trained staff are available to check and administer the treatment who have
been assessed as competent to continue the protocol.
In exceptional circumstances chemotherapy may be initiated outside working hours for
haematological malignancies where the clinician determines that delay would be detrimental to a
patient’s wellbeing.
Outside normal working hour’s pharmacy cannot guarantee an on call pharmacist with the
necessary skills will be available, in this situation a discussion between the clinician and the on
call pharmacist will be undertaken to decide on the most appropriate clinical management plan.
3. Prescribing
The clinical decision to initiate a course of chemotherapy should be restricted to a consultant
oncologist/haemato-oncologist and ST3 and above medical trainee staff who have been trained
and assessed as competent to undertake this task. This clinical decision must be documented in
the patient’s notes.
The first cycle of a course of chemotherapy should ideally be prescribed, signed and dated by the
initiating consultant however a ST3 and above medical trainee staff or specialist staff grade with
skills and experience in the tumour type sub-specialism in which the chemotherapy is being
prescribed may be delegated this role by the initiating consultant.
Prior to the prescribing of the first cycle of chemotherapy the prescribing doctor must ensure the
following information is available and documented within the patient’s record:
Guideline for the safe prescribing, handling and administration of chemotherapy for adults in
the treatment of malignant disease
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History of specific diseases or conditions affecting fitness for chemotherapy. This includes
that the minimum physical and investigational requirements have been met
Performance status;
Prior history of chemotherapy;
Current patient medication affecting chemotherapy;
That informed consent has been obtained;
Regimen against departmental protocols;
The number of and frequency of cycles intended
That a holistic assessment has been carried out(or an appointment for pre-chemotherapy
appointment is booked where this will be undertaken)
Height/Weight
Indication for treatment i.e. Neoadjuvant, Adjuvant, Palliative, Concurrent, Curative.
Medical Doctors who are assessed as competent to prescribe chemotherapy and are on the list of
doctors identified as such, should be the only doctors prescribing chemotherapy for malignant
disease in the Trust, this includes oral and intravenous systemic chemotherapy. Doctors, who are
identified as competent to prescribe chemotherapy, are to be of Consultant, ST3 and above
medical trainee staff or Specialist Staff Grade only.
A consultant, ST3 and above medical trainee staff or specialist staff grade with skills and
experience in the tumour type sub-specialism in which the chemotherapy is being prescribed
should undertake dose modifications or to cease the treatment.
A non-medical independent prescriber with skills and experience in the tumour type subspecialism in which chemotherapy is being prescribed may undertake the prescribing of
subsequent cycles of chemotherapy.
A non-medical independent prescriber with skills and experience in the tumour type subspecialism in which the chemotherapy is being prescribed may undertake dose modifications or to
cease the treatment following discussion with consultant or ST3 and above medical trainee staff.
Undertaking dose modifications/stopping anti-cancer treatment (and details of discussion with the
senior clinician) must be documented in the patient’s notes and electronic chemotherapy
prescribing record.
A non-medical independent prescriber may also undertake dose modifications if agreed
parameters for dose modifications are stipulated within the chemotherapy protocol.
The pre-prescribing of chemotherapy for subsequent cycles should be utilised whenever possible
to enable effective working practices.
A list of clinicians assessed as competent to prescribe should be kept and updated annually. This
list should clearly state which clinicians can prescribe first cycle and who can prescribe
subsequent cycles. Before dispensing, the screening pharmacist should satisfy themselves that
the prescribing doctor is on the Trust list of competent clinicians (including non-medical
prescribers) to prescribe chemotherapy. This includes ward discharge prescriptions, oral and
intravenous agents.
FY1/FY2 must not prescribe or transcribe chemotherapy
Locum doctors must not prescribe or transcribe chemotherapy
Non medical independent nurse prescribers who have not completed specialist training
must not prescribe or transcribe chemotherapy.
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the treatment of malignant disease
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If a patient is admitted to hospital on chemotherapy this should not be prescribed, rewritten or
transcribed without specialist advice.
It is a requirement of the “Chemotherapy: Ensuring Quality and Safety” (NCAG 2009) report that
pre-printed prescriptions as a minimum or ideally a fully validated electronic prescribing system
should be utilised for the prescribing of chemotherapy.
At Worcestershire Acute hospitals NHS Trust regimen specific pre-printed prescriptions or
electronic prescriptions should be used for all prescribing when available or if not available a blank
chemotherapy template prescription must be completed.
Electronic prescriptions should not be modified by hand but represcribed on the electronic
prescribing system when a dose modification is required as if the prescription is modified by hand
there will be no auditable trail and presents the risk of subsequent cycles not including the dose
modification.
The same process of care should be used for the administration of oral and parenteral
chemotherapy.
Each treatment protocol should demonstrate the following information: 
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Cancer Type
Name of regimen and therapeutic drugs including doses
Therapeutic intent
Doses of therapeutic drugs
Routes of administration
Number of cycles or whether this is indeterminate
Length of cycle and number and timing of administrations within cycle
Pre-treatment investigations for first and subsequent cycles
Supportive drugs within each cycle
Therapeutic dose modifications and their indications
If a patient is 30% over their ideal body weight the need for dose reduction or dose capping
should be considered.
Cancer chemotherapy should be prescribed utilising a protocol available on a Trust approved eprescribing system or a protocol approved at Haematology MDT.
In any instance of off protocol prescribing, the screening pharmacist must satisfy themselves that
the regime used is a recognised regime and complete an “off protocol prescribing form” as
detailed in the professional screening standards. The lead pharmacist cancer and aseptics (AH
and WRH) will collate this information for discussion at the Haematology/Oncology Directorate
Meeting. For Haematology patients, deviations will be discussed at the Haematology/Oncology
Directorate Meeting in addition to the haematology MDT.
4. Reconstitution and Preparation of Chemotherapy Drugs
All chemotherapy drug reconstitution will be carried out in pharmacy aseptic suites by suitably
trained pharmacy staff on receipt of an appropriately completed prescription.
Injectable chemotherapy must be supplied to clinical areas reconstituted in accordance with
Worcestershire Acute Hospitals NHS Trust Medicines Policy (WAHT-CG-580)
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the treatment of malignant disease
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Routine Prescriptions should be sent to pharmacy with at least 48hours notice wherever possible
to enable pharmacy staff to manage the workload effectively during normal working hours i.e.
Monday to Friday 9am – 5pm. There is an on-call pharmacist for out of hour’s requests; however
this is for emergency situations only, pharmacy cannot guarantee availability of staff with the
required knowledge and expertise outside normal working hours to re-constitute chemotherapy
drugs.
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All chemotherapy prescriptions should be professionally checked by an oncology pharmacist,
following pharmacy professional checking standards.
A list of designated pharmacists should be kept in each aseptic suite.
A list of designated checkers should be kept in each aseptic suite
Chemotherapy will be reconstituted by a pharmacy technician or ATO who will have undertaken
and completed a validated training programme approved by the lead pharmacist for cancer and
aseptic services at either the Alexandra Hospital or Worcestershire Royal Hospital.
All discrepancies must be clarified with the prescribing clinician prior to dispensing of medications.
All changes will be clearly annotated on the prescription and signed and dated by the pharmacist.
5. Transportation of Chemotherapy
Reconstituted and oral chemotherapy must be transported in designated appropriately labelled,
sturdy, secure leak proof bags.
Pneumatic tubes must not be used for the transportation of chemotherapy.
Chemotherapy drugs that are transported between hospital sites should be placed in transport
bags or boxes. These must be clearly labelled as “Chemotherapy – handle with care”. Details of
recipient and delivery address should be clear.
Personnel transporting chemotherapy between hospital sites should have clearly defined
pathways for reporting any problems during transit. Staff should undergo regular updates in the
transportation of dangerous goods and an audit trail of training should be available.
Chemotherapy should be transported to the clinical area on the day required whenever possible,
otherwise storage must be as detailed in following section.
6. Storage in Clinical Area’s
Ideally reconstituted chemotherapy drugs should not be routinely stored within clinic areas but
received from pharmacy on the day required. However in some situations e.g. geographical
restrictions or weekends, storage may be necessary within clinical areas
A member of nursing staff must receive the chemotherapy drug at its destination.
Nurses are responsible for the correct storage of chemotherapy drugs once delivered to the ward
and departments prior to use.
Storage will be as per indicated on the advisory label from pharmacy.
If temporary storage is required in the clinical area i.e. overnight or weekend it will be either in
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A designated locked drug refrigerator with temperature of 2-8 C.
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A designated locked cupboard within the clean utility area which clearly states the usage.
Chemotherapy will be stored separately from other drugs.
Oral chemotherapy will be stored either in a designated cupboard or in a patient
medication locker by the patient’s bed. Patients prescribed thalidomide or Lenolidamide
should have these stored in their locked patient medication locker to reduce the risk of
error.
Any refrigerators utilised should be able to be monitored to ensure temperature is registering 2-8
C e.g. electrical temperature recording display.
7. Administration of Chemotherapy
Systemic chemotherapy for Haematology/Oncology patients should only be administered in the
dedicated facilities as stated in section one.
Prior to the commencement of a new course of chemotherapy a pre-treatment
consultation/assessment should be undertaken. This assessment should address not only the
relevant physical factors but should also include their perceived social, psychological and
emotional needs. This appointment should take place separately from and after any consultations
at which the chemotherapy treatment plan is agreed with them and should have a designated
appointment of a minimum of 30 minutes to enable patients needs to be assessed and questions
answered.
At this assessment a discussion relating to their carers and their potential needs should also be
undertaken.
Following these assessments any appropriate agreed referrals should be initiated.
The health professional administering the first dose of chemotherapy will ensure a consent to
treatment form has been completed.
The health professional administering the chemotherapy must ensure that the patient has
received all the information required pertinent to their needs. As a minimum prior to the first
course of treatment the nurse should ensure the patient has received the 24 hour emergency
contact information. Additionally the patient should have received regimen and drug specific
information; at Worcestershire Acute Hospitals NHS Trust the standard for this is the Macmillan
Cancer Support Information supported by local information where appropriate.
A registered health professional who prescribes chemotherapy for an identified patient (nurse,
doctor or pharmacist) should not routinely undertake the task of checking or administering
chemotherapy to this patient.
Only in extenuating circumstances should a prescriber undertake the role of second checking of
chemotherapy prior to administration however a health professional should not administer
chemotherapy they have prescribed.
Checking of chemotherapy must be undertaken by two health professionals who are also
authorised to administer chemotherapy in accordance with Worcestershire Acute Hospitals NHS
Trust Medicines Policy (WAHT-CG-580)
A register of staff authorised to administer and check chemotherapy must be available and
updated annually.
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The two competent practitioners checking the chemotherapy should ensure that the prescription
and the chemotherapy drugs pharmacy label are identified for
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Patients name
Patients hospital number
Dosage of all medications
Route of administration
Infusate if an infusional treatment
The two competent practitioners checking the chemotherapy will ensure that storage has been
according to that stated on the label.
If a patient is provided with trials medications these must only be used for that patient including
supportive medications provided as part of the trial. It is also important that if supportive
medications are supplied as part of a trial that these are utilised in preference to stock supportive
medications.
The two competent practitioners checking the chemotherapy should ensure that all of the
medication will be administered prior to the expiry date. If a chemotherapy drug is due to expire
during an infusion, pharmacy should be consulted prior to commencement.
All patients undergoing chemotherapy, in any setting, will have an identification band in place,
which must contain all relevant patient details as per Trust policy (WAHT-CG-019) i.e. Surname,
First name, D.O.B, Patients NHS number or ten digit hospital number.
The registered health professional administering the chemotherapy is responsible for the safe
administration of chemotherapy to the correct patient.
The identification of the patient for chemotherapy will take place prior to the commencement of
administration.
For patients receiving regimes containing multiple infusions, active identification will be repeated
prior to the commencement of each individual bag of chemotherapy
The registered health professional involved in the administration and the checking of the
chemotherapy will positively and actively identify the patient through questioning: requesting the
surname, first name and date of birth in patients who are judged capable of giving a reliable
response.
The registered health professional will check that the details on the patient’s identification band
match those on the chemotherapy prescription and clinical records:
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Surname
First name
Date of birth
Patient ten digit Hospital identification number or NHS number.
The above details MUST be found to be identical on the wristband and the chemotherapy
prescription form.
If an identity band needs to be removed, it is the responsibility of the person removing it to ensure
that it is replaced.
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For patients who cannot wear an identity band because of their clinical condition or treatment, it is
imperative to correctly identify the patient at each step in the care process. When a patient is not
wearing an identity band, best practice identification is to use several elements:
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Last name – Ask patient and cross reference with relevant clinical records
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First name – Ask patient and cross reference with relevant clinical records
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Date of birth – Ask patient and cross reference with relevant clinical record
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Any known allergies- Ask patient and cross reference with relevant clinical record
In the extenuating circumstance of patient being unable to confirm identity (e.g. confusion or
unconsciousness) identification can be checked with relatives (WAHT-CG-019) cross checking
with any paperwork available on patient e.g. driving licence, ID card, bank cards or letter with
home address.
If a discrepancy should occur the following actions will apply (taken from the Policy to Identify all
Patients WAHT-CG-019)
Procedure If Patient Misidentification Occurs
In the event of the patient’s identity band showing incorrect patient details the following action
must be taken:
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Remove incorrect wristband and retain for investigation.
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Identify the patient following the steps described above and apply a correct and verified
patient identity band.
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Check patient has not received incorrect drug/treatment.
Complete a Datix incident electronic form and keep the incorrect identity band for the investigating
officer (each patient misidentification must be investigated to determine the cause and reasonable
action taken to reduce the likelihood of reoccurrence)
A competent practitioner in the administration of chemotherapy will establish
that the following information is documented in the patient’s records (or there is electronic access
to):
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history of specific diseases or conditions affecting fitness for chemotherapy. This includes
that the minimum physical and investigational requirements have been met
critical test results;
regimen and individual drug identification;
diluents and dilution volumes, and any hydration;
that supportive drugs have been given as per prescription;
administration route and duration;
cycle number;
the administration as per the schedule within the cycle;
history of toxicities and complications from previous cycles;
dose modifications or delays and reasons have been documented and implemented
assessment of response according to the relevant regimen and treatment intention has
been undertaken/is booked.
The competent practitioner administering the chemotherapy will ensure the prescription is signed
and dated and in accordance with an agreed chemotherapy protocol or that pharmacy have
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agreed to or obtained the necessary permission to use a regime outside the normal list of
protocols.
The nurse administering chemotherapeutic agents should have knowledge of disease
processes, drug classifications, pharmacological indications, actions, side-effects, adverse
reactions, method of administration (that is, intravenous bolus, intravenous infusion, etc.), rate of
delivery, treatment aim (that is, neoadjuvant, adjuvant, palliative or curative), drug properties (that
is, vesicant, non-vesicant or irritant), and specific drug calculations of dose and volume relative to
age, height and weight, or body surface area (RCN 2010)
The nurse should review the prescription for appropriateness for the patient’s age and
condition, access device, dose, route of administration and rate of infusion/speed of the
bolus injection.
The health professional administering the chemotherapy will explain the procedure to the patient.
The administration of certain chemotherapy regimens can be overseen by appropriately qualified
nurses without the presence of oncology/haematology medical staff on site provided that the
requirements of the appropriate protocol for nurse led administration of anticancer treatment at
Worcestershire Acute Hospitals NHS Trust have been adhered to.
7.1 Administration of Intravenous Chemotherapy
The placement and utilisation of a venous access device must follow the principles within
the Trust’s Protocol for the insertion, management and removal of peripheral vascular
devices (cannula) (WAHT-INF-035)
A competent practitioner in consultation with the patient should select the most appropriate
vascular access device.
The selection of the appropriate route for venous access should be based on the patients
short and long term best interests and wellbeing.
Chemotherapy should not be given if the health practitioner is in any doubt regarding the
safety of a vascular access device.
If the practitioner has any doubts in relation to the vascular access device the patient
should be recannulated
Ideally a new peripheral cannula should be sited immediately prior to chemotherapy
administration.
The vascular access device should be selected by a practitioner competent to assess and
utilise them appropriately. A small gauge Teflon or silicone cannula is recommended.
In no circumstances should a metal butterfly needle be utilised to for the administration of
chemotherapy
The practitioner when assessing a patient for cannulation will include in their assessment:
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The condition of the vein
Recent venepuncture / cannulation attempts’ ensuring that cannulation is proximal
to these.
The age of the patient
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Previous chemotherapy treatment
Avoid limbs where there may be lymphatic impairment due to diagnosis, surgery
and radiotherapy even if no obvious signs of lymphoedema.
Avoid areas of joint flexion, tendons, nerves or arteries
Avoid anti-cubital fossa particularly if utilising vesicant
Avoid limbs with neurological weakness
Be aware of the potential difficulties of assessing and monitoring venous access in
patients with body art.
When assessing vascular access, consideration should be given to a central access
device for patients in the following scenarios: 
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Chemotherapy protocol includes chemotherapy being given continuously
Poor peripheral access
Needle phobic patients may wish to consider a central venous access device
Patients receiving vesicant chemotherapy agents
The venous access device should be inserted using an aseptic technique.
The vascular access device should be secured with a sterile, transparent, waterproof
dressing such as Smith & Nephew IV 3000.
Ideally a practitioner should only make two attempts at cannulation. If both attempts fail the
procedure should be referred to another experienced colleague.
The site of the cannula placement and date should be documented within the patient’s
clinical records. This should also include the number and sites of attempted cannulations.
Venous access should be assessed and tested immediately prior to and frequently
throughout administration of any chemotherapy drugs, utilising a number of monitoring
methods to monitor for extravasation these include
 Increased resistance when administering IV drugs
 Slow or sluggish infusion
 Change in infusion flow
 Lack or loss of blood return from the cannula
 The patient must be informed to report any change in sensation, burning or pain at
any time during administration of chemotherapy.
If multiple drugs are prescribed within the chemotherapy protocol, ideally vesicants should
be administered first when vein integrity is at its best. However there are notable
exceptions where it is clinically indicated within the protocol that a non vesicant should be
given first.
If a non vesicant is administered first for clinical reasons the patency of the cannula should
be reassessed prior to administration of vesicants. If there are doubts regarding the
integrity of the cannula or the vein the patient should be recannulated.
When administering bolus vesicant they should be administered through the side arm of a
fast flowing compatible fluid drip.
The delivery of chemotherapy irrespective of the agent being vesicant or not, is about the
individual patient and the clinical assessment any practitioner makes at the time of the
administration and will show huge inter and intra patient variability. The administration of
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chemotherapy needs to be guided by the skill and clinical judgment of the practitioner in
the specific and individual circumstances of that administration.
It is known that certain pharmacological and formulation issues such as pH make a
difference ; volume and temperature are also important, larger volumes will require slower
administration and the greater the temperature gradient between the administered drug
and physiological 36.8 the greater the degree of ‘venous shock’ and consequential shut
down and risk of extravasation.
A number of regimens may now require patients to receive an infusional vesicant; patients
receiving a vesicant in this way should be closely monitored for signs of extravasation as
there may be a theoretical increased risk of a larger volume extravasation.
In response to the NPSA alert RRR004 Vinca Alkaloids should only be supplied in the form
of minibags for infusion
The prescribed dose of vinca alkaloids should be supplied ready to administer in a 50ml
minibag of sodium chloride 0.9% (for some brands of vinorelbine glucose 5% solution for
injection may be used instead of sodium chloride 0.9%).
All vinca alkaloid doses should be labelled 'For Intravenous Use Only - Fatal If
Administered by Other Routes'.
There should be use of colour and design on the label, outer packaging and delivery bags
to further differentiate minibags containing vinca alkaloids from other minibag infusions.
(NPSA/2008/RRR004).
The vinca minibag should be infused intravenously over 5 - 10 minutes
A compatible fluid should be utilised to assess the vein and the vascular access device:  Prior to administration
 During administration
 Between different drugs
 After administration
Line patency should also be checked by stopping any infusate and observing for back-flow
into cannula on a regular basis.
If an infusion pump is being utilised for administration of chemotherapy the cannula site
and patency of the vein must be checked regularly as a pump may continue to operate
initially following an extravasation.
If administration is via a central venous access device as well as above principles, the
Trust guideline “Central Venous Access Devices (CVAD) Guideline for insertion and
management“(WAHT-INF-017) should be followed.
7.2 Administration of Oral Chemotherapy
Staff administering oral chemotherapy should have read and understood “Standard
Operating Procedure (SOP) for confirming oral anti-cancer and immunosuppressant
medicines to be able to administer to patients at WAHT” (MedPolSOP24)
The prescribing, dispensing and administration of oral chemotherapy should adhere to the
same safeguards as for the administration of intravenous chemotherapy.
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Written consent to treatment must be obtained prior to patients commencing oral
chemotherapy
A primary care physician may only undertake dose modifications of oral chemotherapy
following discussion with the initiating consultant and as part of a shared care protocol.
The utilisation of home care services for Haematology patients receiving protein kinase
inhibitors is for the delivery of the medication only. The responsibility for the initiation and
prescribing remains with the Acute Trust Haematologists.
All personnel handling chemotherapy should be aware of health and safety issues
pertaining to the handling of oral chemotherapy
The administration of oral chemotherapy will usually be undertaken in the patient’s home
environment. However the hospital-based team must ensure the patient is fully informed
and has up to date verbal and written information about their medication, and has 24-hour
contact numbers for support and advice if required.
Patients should be informed of how to handle and store their medications.
Ideally oral formulations should not be crushed, halved, opened or chewed. If a patient is
unable to swallow tablets or capsules pharmacy should be contacted for advice.
The hospital-based team must ensure the patient or carer understands: 






How and when to take their medications including any gaps in treatment
How to seek advice if a problem arises
What to do if a dose is missed
What to do in the event of vomiting after a dose
Side effects of treatment
Who will prescribe and dispense future courses
How to handle and store their medications
Patients admitted during a course of oral chemotherapy should have their chemotherapy
discussed with the acute oncology team (Mon-Friday 9-4:30) or the on call haematologist
or oncologist at the treating centre
If a patient is admitted to hospital as an emergency on chemotherapy this should not be
prescribed, rewritten or transcribed without specialist advice.
Further advice can be found in Appendix 3 (“Prescribing and Transcribing of Oral AntiCancer & Immunosuppressant Medicines on Admission to Hospital”)
7.3 Administration of Sub-Cutaneous / Intramuscular Chemotherapy
The prescribing, dispensing and administration via these routes for chemotherapy should
adhere to the same safeguards as stated in previous sections
Consent for treatment should be obtained prior to the commencement of a course of
treatment.
Vesicants must NEVER be given sub-cutaneously / intramuscularly.
Following administration a waterproof dressing should be applied to the site of injection.
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8. Health and Safety
Health and safety is not an individual issue but a team issue whereby each member ensures
safety for themselves, their colleagues, their patients and the environment in which they are
working.
Handling chemotherapy drugs is an activity that should not be rushed thereby aiming to ensure
that practice remains safe at all times.
All practices relating to chemotherapy should be undertaken adhering to the COSHH guideline for
the safe handling of cytotoxics (HSE 2003)
8.1 Minimising Exposure
The utilisation of personal protective equipment will minimise the risk of exposure to
hazardous substances
Pharmacy staff preparing chemotherapy drugs within the pharmacy aseptic suites will
carry out all manipulations of chemotherapy products in an externally vented negative
pressure isolator suitable to the purpose of handling chemotherapy products.
8.2 Personal Protective Equipment to be used when handling chemotherapy
The use of personal protective equipment (PPE) can shield staff from exposure to
chemotherapy drugs and minimise health risks however the following criteria must be met
 Suitable for the task
 Suitable for the wearer and the environment
 Compatible with other PPE in use
 In good condition
 Worn correctly
Nitrile gloves should be worn at all times when handling chemotherapy. These should be
changed after every patient interaction or if they become damaged or contaminated
Gloves must be worn at all times appropriate to the task being undertaken
Cuts and grazes should be covered with a waterproof dressing.
Plastic aprons should be worn at all times during the administration of chemotherapy and
changed after every patient interaction.
The use of eye protection should be considered whenever splashes or sprays of
chemotherapy maybe generated e.g. chemotherapy spillage. (MARCH guidelines
accessed September 2010)
Eyewash should be readily available within the department in case of accidental
contamination.
All protective clothing utilised for the administration and handling of chemotherapy waste
will be placed in clinical waste bags for incineration.
8.3 Protective Clothing for Chemotherapy spillage
The Trust “Policy for Handling the Spillage of Cytotoxic and Anti-Cancer Drugs” (WAHTPHA-002) provides full guidance on handling of cytotoxic spillages
Protective clothing should be worn and disposed of as stated in the above guidelines
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Spillage kits must be easily accessible in areas where chemotherapy is handled.
8.4 Disposal of Chemotherapy Waste.
The Trust “Waste Management Policy” (WAHT-CG-481) provides full guidance for the
management of chemotherapy waste
All protective clothing utilised for the administration and handling of chemotherapy waste
will be placed in clinical waste bags for incineration.
All equipment either contaminated or potentially contaminated with chemotherapy must be
disposed of in a rigid sharps container with purple lids labelled for chemotherapy waste
which conforms to EWC 18 01 03*/18 01 08* (European Waste Catalogue (EWC) Coding
for Waste from Natal Care, Diagnosis, Treatment or Prevention of Disease in Humans)
Giving sets should ideally not be removed from infusion bags prior to disposal to minimise
aerolisation.
Purple lidded chemotherapy sharps bins should not be allowed to accumulate within a
clinical area and practitioners should ensure they are removed on a regular basis.
Part used doses of chemotherapy should be capped off or in the case of infusions the
giving set should not be removed but the end of the giving set capped off, placed in a
chemotherapy sharps bin and sent for incineration.
Unused chemotherapy should be returned to pharmacy transported as stated in section 5.
8.5 New and expectant mothers
Employers are required under the Management of Health and Safety at Work
(MHSW) Regulations 1999, to assess the risks to the health and safety of their
employees and others, including risks to new and expectant mothers and their children.
Employees should notify their managers as soon as possible if they are pregnant, trying to
conceive or are breastfeeding and work in a chemotherapy area. This is particularly
important as the greatest risk is during the first three months of pregnancy, when rapid cell
division and differentiation occurs however the associated potential risk to chemotherapy
administrators is unclear (National Institute for Occupational Safety and Health (NIOSH)
2004).
As pregnancies are often unplanned or unknown for several weeks the emphasis should
therefore be to ensure safe practice at all times for all staff caring for patients receiving
chemotherapy
When an expectant, newly delivered or breast feeding mother informs her manager in
writing of her condition, the manager must immediately undertake a specific risk
assessment on the work activities of the employee using the Trust pregnant workers risk
assessment form and any appropriate action carried out as per the family leave policy
(WAHT-HR-089).
Pregnant women or staff planning a pregnancy should be advised of the potential risks
associated with handling chemotherapeutic agents and given the opportunity to refrain
from preparing or administering these agents (RCN 2010).
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New, expectant and breastfeeding mothers should be specifically advised against any
direct involvement in the management of a cytotoxic drug spillage, extravasation or
handling of body fluids or excreta due to the increased risk of exposure to cytotoxic’s or
their metabolites.
9. Risk Management
The priority in the provision of chemotherapy services is the safety of patients, carers and staff.
As stated in section 2 the administration of chemotherapy should be initiated within normal
working hours unless under exceptional circumstances as described in the aforementioned
section
The Trust lead chemotherapy nurse in discussion with the nurse manager at each site (or a
delegated person in their absence) should ensure that there are appropriate numbers of staff with
the required level of training to:




Handle chemotherapy drugs and waste appropriately
Administer chemotherapy drugs in an unhurried manner and with minimal interruptions
Monitor patients with infusional treatments
Be able to deal with complications and emergencies as they arise.
If the lead chemotherapy nurse in consultation with the nurse manager at each site (or a
delegated person in their absence) assesses that the safety of patients is or is at risk of being
compromised, contact should be made with other clinical chemotherapy services to assess the
feasibility of support being made available. If there is no support available the lead chemotherapy
nurse in consultation with the nurse manager at each site should discuss with responsible
clinician(s) the rescheduling of chemotherapy treatments.
If the lead oncology pharmacist assesses that the capacity for reconstitution has been or is at
risking of breaching safety levels they will inform the nursing staff of difficulties that will delay the
dispensing of chemotherapy and support will be requested from within the trust.
The lead chemotherapy nurse, the nurse managers for each clinical chemotherapy suite in
collaboration with pharmacy services will regularly assess chemotherapy workload trends to
ensure appropriate service provision.
There will be an annual review to ensure workforce and capacity is available to respond to
changes in clinical practice.
All adverse incidents/ errors must be reported via the Trust Datix incident reporting system. This
includes prescribing errors that through pharmacy checking procedures are identified and
rectified.
All adverse incidents reported via the Trust Datix system will be reviewed and discussed at the
Haematology/Oncology directorate meetings, identifying appropriate action plans are developed
and implemented to mitigate the risk.
The Haematology/Oncology Directorate Management Team will escalate risks/incidents as
appropriate from the analysis and investigations of any adverse incidents.
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Monitoring Tool
STANDARDS
Datix errors relating to the
prescribing/handling and
administration of
chemotherapy will be
reviewed on a 6 monthly
basis to assess for any
trends/deviations from the
guidelines and for
mitigating action where
appropriate to be
assessed, discussed and
subsequently
implemented by the
Haematology/Oncology
directorate meeting and
medicines safety
committee
%
100%
RESPONSIBLE
FOR REVIEWING
Lead
Chemotherapy
Nurse
CLINICAL
EXCEPTIONS
References
Allwood M, Stanley A, Wright P (Eds)
NHS England
Dougherty L & Lister S (Eds)
Health and Safety Executive
Health and Safety Executive
Joint Council for Clinical Oncology (JCCO)
Quality control in cancer chemotherapy.
managerial and procedural aspects 1994.
Medicines Control Agency
National Chemotherapy Advisory Group
National Patient Safety Agency
www.npsa.nhs.uk
National Institute for Occupational Safety
and Health at www.cdc.gov/NIOSH
Royal College Nursing (RCN)
Royal College of Nursing (RCN)
Cytotoxic’s handbook 4th Ed
Radcliffe Medical Press Ltd
Manual for cancer services chemotherapy
measures 2014 Gateway ref 16104
The royal Marsden manual of clinical
nursing procedures 8th Ed. April 2011
COSHH Regulations 2003
Management of Health and Safety at Work
Regulations 1999. (accessed March 2014)
Rules and guidance for pharmaceutical
manufacturers and distributors. 2002
Chemotherapy: Ensuring quality and safety
2009
Rapid response report
NPSA/2008/RRR04 using Vinca Alkaloid
minibags (adult /adolescent Units) 2008
(accessed March 2012)
Preventing occupational exposure to
antineoplastic and other hazardous drugs in
the healthcare setting 2003 (accessed
March 2012)
The administration of cytotoxic
chemotherapy-clinical practice guidelines;
recommendations 1998.
Standards for infusion therapy 3rd edition
2010
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Contribution List
Key individuals involved in developing the document
Name
Sue Sharp
Designation
Chemotherapy/Radiotherapy Project Nurse
Circulated to the following individuals for comments on review March 2014
Name
Glenis Adams
Sam Leonard
Rachael Desogus
Richard Newman
Lisa Rowberry
Stephanie Cook
Heather Perry
Gurminder Bhogal
Tina Evans
Dr D Farrugia
Dr J Bowen
Dr R Counsell
Dr C Candish
Dr L Capaldi
Dr C Irwin
Dr S Sothi
Dr J Hamilton
Dr D Hrouda
Dr M Churn
Dr P Koh
Dr F Clark
Dr E Maughan
Dr T Skibbe
Dr J Mills
Dr M Crowther
Dr Pemberton
Dr Shafeek
Dr K Thein
Ms C Burton
Mr P James
Ms T Thomas
Mr T Rees
Ms C Davies
Ms L Colbourne
Ms A Jones
MS S Toland
Mrs V Milner
Designation
Lead Nurse Oncology/Haematology/Chemotherapy
Chemotherapy Suite Manager- Alex
Chemotherapy Sister Kidderminster
Chemotherapy Suite Manager-WRH
Laural 3 Ward Manager
Oncology Pharmacist
Oncology Pharmacist
Pharmacist
Clinical Pharmacist Team Leader
Consultant Medical Oncologist
Consultant Clinical Oncologist
Consultant Clinical Oncologist
Consultant Clinical Oncologist
Consultant Clinical Oncologist
Consultant Clinical Oncologist
Consultant Clinical Oncologist
Consultant Clinical Oncologist
Consultant Clinical Oncologist
Consultant Clinical Oncologist
Consultant Clinical Oncologist
Consultant Haematologist
Consultant Haematologist
Consultant Haematologist
Consultant Haematologist
Consultant Haematologist
Consultant Haematologist
Consultant Haematologist
Specialist Staff Grade Haematology
CNS Haematology
CNS Haematology
CNS Haematology
CNS Haematology
CLIC Sergeant Specialist nurse
Advanced Nurse Practitioner-Acute Oncology
Nurse Practitioner Acute Oncology Service
Nurse Practitioner Acute Oncology Service
Peer Review Quality Manager
Circulated to the following CD’s/Heads of dept for comments from their directorates /
departments
Name
Mrs A Sullivan
Mr A Makar
Mrs L Mazzocchi
Mrs K McCredie
Mr N Hubbard
Directorate / Department
Lead Cancer Manager/Macmillan Lead Cancer Nurse
Associate Medical Director Cancer Services
Haematology/oncology Directorate manager
Haematology/Oncology Support Manager
Pharmacy Director
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Appendix 3
Management of patients admitted to hospital on oral chemotherapy or
immunosuppressant therapy.
PRESCRIBING AND TRANSCRIBING OF ORAL
ANTI-CANCER & IMMUNOSUPPRESSANT MEDICINES ON ADMISSION TO HOSPITAL
FY1 FY2 AND NMPs WITHOUT SPECIALIST TRAINING MUST NOT PRESCRIBE THESE MEDICINES.
DO NOT PRESCRIBE (INCLUDES CHART REWRITES) OR TRANSCRIBE THESE MEDICINES WITHOUT SPECIALIST
ADVICE SEE BELOW.
BE AWARE THAT THE PATIENT MAY BE SUFFERING FROM SIDE EFFECTS FROM THESE MEDICINES WHEN THEY
ARE ADMITTED TO HOSPITAL.
ABIRATERONE
FLUDARABINE
PROCARBAZINE
AXITINIB
FLUOROURACIL
REGORAFENIB
AZATHIOPRINE
HYDROXYCARBAMIDE
RUXOLITINIB
BEXAROTENE
GEFITINIB
SIROLIMUS
GOLD (SODIUM AUROTHIOMALATE)
BOSUTINIB
SORAFENIB
SULPHASALAZINE
BUSULPHAN
IDARUBICIN
CAPECITABINE
IMATINIB
SUNITINIB
CHLORAMBUCIL
LAPATINIB
TACROLIMUS
CRIZOTINIB
LENALIDOMIDE
TEGAFUR
LEFLUNOMIDE
CYCLOPHOSPHAMIDE
TEMOZOLAMIDE
CICLOSPORIN
LOMUSTINE
TEYSUNO
D-PENICILLAMINE
MELPHALAN
THALIDOMIDE
DABRAFENIB
MERCAPTOPURINE
TIOGUANINE
DAPSONE
METHOTREXATE
TOPOTECAN
DASATINIB
MITOTANE
TREOSULPHAN
ENZALUTAMIDE
MYCOPHENOLATE
TRETINOIN
ERLOTINIB
NILOTINIB
VANDETANIB
ESTRAMUSTINE
PAZOPANIB
VEMURAFENIB
ETOPOSIDE
POMALIDOMIDE
VINORELBINE
EVEROLIMUS
PONATINIB
VISMODEGIB
N.B THIS IS NOT AN EXHAUSATIVE LIST- IF A MEDICINE IS NOT ON THE LIST BUT USED AS
ANTI-CANCER OR IMMUNOSUPPRESSANT THERAPY SEEK ADVICE AS DETAILED BELOW
ONCOLOGY
HAEMATOLOGY
RHEUMATOLOGY AND OTHER
MEDICAL CONDITIONS
IN HOURS
MONDAY-FRIDAY
9-4:30pm
CONTACT ACUTE ONCOLOGY
SERVICE 30048/30049 OR BLEEP
398
CONTACT ACUTE ONCOLOGY
SERVICE 30048/30049 OR BLEEP
398
ADMITTING TEAM TO REVIEW AND
PRESCRIBE IF APPROPRIATE OR
CONTACT FOR SPECIALIST ADVICE
Rheumatology Advice Line EXT 33466
or ST via switchboard
OUTSIDE WORKING
HOURS
PATIENTS TREATED AT GARDEN
SUITE-UHCW-02476 965525
UHCW-02476 964000 BLEEP
1641
PATIENTS TREATED AT
KIDDERMINSTER
RWH- 01902 694012
PATIENTS TREATED ON ROWAN
GHFT-0300 422 3444
CONTACT THE ON CALL
HAEMATOLOGIST VIA
SWITCHBOARD TO ASCERTAIN
WHETHER MEDICINES SHOULD BE
CONTINUED.
ADMITTING TEAM TO REVIEW AND
PRESCRIBE IF APPROPRIATE, OR
ACCESS SPECIALIST ADVICE IN HOURS
AS ABOVE
PATIENTS ON THESE MEDICINES SHOULD HAVE BEEN GIVEN INFORMATION TO REASSURE THEM THAT THEY
MAY NEED TO STOP THESE MEDICINES IF ADMITTED TO HOSPITAL
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Supporting Document 1 - Equality Impact Assessment Tool
To be completed by the key document author and attached to key document when submitted
to the appropriate committee for consideration and approval.
Yes/No
1.
Comments
Does the policy/guidance affect one group
less or more favourably than another on the
basis of:
 Race
No
 Ethnic origins (including gypsies and
No
travellers)
 Nationality
No
 Gender
No
 Culture
No
 Religion or belief
No
 Sexual orientation including lesbian,
No
gay and bisexual people
 Age
No
2.
Is there any evidence that some groups are
affected differently?
No
3.
If you have identified potential
discrimination, are any exceptions valid,
legal and/or justifiable?
N/A
4.
Is the impact of the policy/guidance likely to
be negative?
N/A
5.
If so can the impact be avoided?
N/A
6.
What alternatives are there to achieving the
policy/guidance without the impact?
N/A
7.
Can we reduce the impact by taking
different action?
N/A
If you have identified a potential discriminatory impact of this key document, please refer it to Human
Resources, together with any suggestions as to the action required to avoid/reduce this impact.
For advice in respect of answering the above questions, please contact Human Resources.
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Supporting Document 2 – Financial Impact Assessment
To be completed by the key document author and attached to key document when submitted to the
appropriate committee for consideration and approval.
Title of document:
Yes/No
1.
Does the implementation of this document require any additional
Capital resources
No
2.
Does the implementation of this document require additional
revenue
No
3.
Does the implementation of this document require additional
manpower
No
4.
Does the implementation of this document release any
manpower costs through a change in practice
No
5.
Are there additional staff training costs associated with
implementing this document which cannot be delivered through
current training programmes or allocated training times for staff
No
Other comments:
N/A
If the response to any of the above is yes, please complete a business case and which is signed by your
Finance Manager and Directorate Manager for consideration by the Accountable Director before progressing
to the relevant committee for approval
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