Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
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 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 WAHT-NUR-064 Version 5.1 Page 1 of 24 WAHT-NUR-064 It is the responsibility of every individual to ensure this is the latest version as published on the Trust Intranet 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 WAHT-NUR-064 Version 5.1 Page 2 of 24 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. 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 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 WAHT-NUR-064 Version 5.1 Page 3 of 24 WAHT-NUR-064 It is the responsibility of every individual to ensure this is the latest version as published on the Trust Intranet 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 WAHT-NUR-064 Version 5.1 Page 4 of 24 WAHT-NUR-064 It is the responsibility of every individual to ensure this is the latest version as published on the Trust Intranet 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 WAHT-NUR-064 Version 5.1 Page 5 of 24 WAHT-NUR-064 It is the responsibility of every individual to ensure this is the latest version as published on the Trust Intranet 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. Guideline for the safe prescribing, handling and administration of chemotherapy for adults in the treatment of malignant disease WAHT-NUR-064 Version 5.1 Page 6 of 24 WAHT-NUR-064 It is the responsibility of every individual to ensure this is the latest version as published on the Trust Intranet 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: 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) Guideline for the safe prescribing, handling and administration of chemotherapy for adults in the treatment of malignant disease WAHT-NUR-064 Version 5.1 Page 7 of 24 WAHT-NUR-064 It is the responsibility of every individual to ensure this is the latest version as published on the Trust Intranet 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. . 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 A designated locked drug refrigerator with temperature of 2-8 C. Guideline for the safe prescribing, handling and administration of chemotherapy for adults in the treatment of malignant disease WAHT-NUR-064 Version 5.1 Page 8 of 24 WAHT-NUR-064 It is the responsibility of every individual to ensure this is the latest version as published on the Trust Intranet 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. Guideline for the safe prescribing, handling and administration of chemotherapy for adults in the treatment of malignant disease WAHT-NUR-064 Version 5.1 Page 9 of 24 WAHT-NUR-064 It is the responsibility of every individual to ensure this is the latest version as published on the Trust Intranet The two competent practitioners checking the chemotherapy should ensure that the prescription and the chemotherapy drugs pharmacy label are identified for 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: 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. Guideline for the safe prescribing, handling and administration of chemotherapy for adults in the treatment of malignant disease WAHT-NUR-064 Version 5.1 Page 10 of 24 WAHT-NUR-064 It is the responsibility of every individual to ensure this is the latest version as published on the Trust Intranet 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: Last name – Ask patient and cross reference with relevant clinical records First name – Ask patient and cross reference with relevant clinical records Date of birth – Ask patient and cross reference with relevant clinical record 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: Remove incorrect wristband and retain for investigation. Identify the patient following the steps described above and apply a correct and verified patient identity band. 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): 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 Guideline for the safe prescribing, handling and administration of chemotherapy for adults in the treatment of malignant disease WAHT-NUR-064 Version 5.1 Page 11 of 24 WAHT-NUR-064 It is the responsibility of every individual to ensure this is the latest version as published on the Trust Intranet 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: The condition of the vein Recent venepuncture / cannulation attempts’ ensuring that cannulation is proximal to these. The age of the patient Guideline for the safe prescribing, handling and administration of chemotherapy for adults in the treatment of malignant disease WAHT-NUR-064 Version 5.1 Page 12 of 24 WAHT-NUR-064 It is the responsibility of every individual to ensure this is the latest version as published on the Trust Intranet 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: 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 Guideline for the safe prescribing, handling and administration of chemotherapy for adults in the treatment of malignant disease WAHT-NUR-064 Version 5.1 Page 13 of 24 WAHT-NUR-064 It is the responsibility of every individual to ensure this is the latest version as published on the Trust Intranet 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. Guideline for the safe prescribing, handling and administration of chemotherapy for adults in the treatment of malignant disease WAHT-NUR-064 Version 5.1 Page 14 of 24 WAHT-NUR-064 It is the responsibility of every individual to ensure this is the latest version as published on the Trust Intranet 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. Guideline for the safe prescribing, handling and administration of chemotherapy for adults in the treatment of malignant disease WAHT-NUR-064 Version 5.1 Page 15 of 24 WAHT-NUR-064 It is the responsibility of every individual to ensure this is the latest version as published on the Trust Intranet 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 Guideline for the safe prescribing, handling and administration of chemotherapy for adults in the treatment of malignant disease WAHT-NUR-064 Version 5.1 Page 16 of 24 WAHT-NUR-064 It is the responsibility of every individual to ensure this is the latest version as published on the Trust Intranet 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). Guideline for the safe prescribing, handling and administration of chemotherapy for adults in the treatment of malignant disease WAHT-NUR-064 Version 5.1 Page 17 of 24 WAHT-NUR-064 It is the responsibility of every individual to ensure this is the latest version as published on the Trust Intranet 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. Guideline for the safe prescribing, handling and administration of chemotherapy for adults in the treatment of malignant disease WAHT-NUR-064 Version 5.1 Page 18 of 24 WAHT-NUR-064 It is the responsibility of every individual to ensure this is the latest version as published on the Trust Intranet 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 Guideline for the safe prescribing, handling and administration of chemotherapy for adults in the treatment of malignant disease WAHT-NUR-064 Version 5.1 Page 19 of 24 WAHT-NUR-064 It is the responsibility of every individual to ensure this is the latest version as published on the Trust Intranet 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 Guideline for the safe prescribing, handling and administration of chemotherapy for adults in the treatment of malignant disease WAHT-NUR-064 Version 5.1 Page 20 of 24 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 WAHT-NUR-064 Version 5.1 Page 21 of 24 WAHT-NUR-064 It is the responsibility of every individual to ensure this is the latest version as published on the Trust Intranet 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 Guideline for the safe prescribing, handling and administration of chemotherapy for adults in the treatment of malignant disease WAHT-NUR-064 Version 5.1 Page 22 of 24 WAHT-NUR-064 It is the responsibility of every individual to ensure this is the latest version as published on the Trust Intranet 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. Guideline for the safe prescribing, handling and administration of chemotherapy for adults in the treatment of malignant disease WAHT-NUR-064 Version 5 Page 23 of 24 WAHT-NUR-064 It is the responsibility of every individual to ensure this is the latest version as published on the Trust Intranet 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 Guideline for the safe prescribing, handling and administration of chemotherapy for adults in the treatment of malignant disease WAHT-NUR-064 Version 5 Page 24 of 24