Download Resource Document - Safe Administration of Antineoplastic Drugs

Resource Document ­ Safe Administration of Antineoplastic Drugs ID 000005 (V2)
Approved: 30 Sep 2009
Last Modified: 29 Feb 2012
Due Review:11 Oct 2013
The purpose of this document is to provide information on the safe administration of antineoplastic drugs via the intravenous, subcutaneous, intramuscular and oral route. Only health care professionals who have attained competency as per institutional guidelines should perform the included procedures. This document should be read in conjunction with: ■
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Clinical Oncological Society of Australia (COSA) 2008 Guidelines for the Safe Prescribing, Dispensing and Administration of Cancer Chemotherapy Cancer Nurses Society of Australia (CNSA) 2010 Position Statement on the Minimum Education Requirements for Nurses involved in the Administration of Anti­Cancer Drugs in the Oncology and Non­Oncology Setting eviQ Resource Document ­ Safe Handling and Waste Management of Hazardous Drugs Prescribing, dispensing and administration errors relating to antineoplastic drugs that result in patient harm are well documented in the literature. The application of, and adherence to appropriate policies and procedures can reduce the risk of medication errors and adverse patient outcomes from occurring. Patient Education Patients and their carers should receive appropriately designed and delivered education, including both verbal and written information on: ■
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the treatment process ● treatment protocol ● blood tests and appointments side effects and management ● self care ● situations that require urgent treatment safe handling precautions In planning education it is important to assess the patient's individual needs including communication and understanding. Link to the
Antineoplastic Drug Patient Education Checklist Patient Consent All patients should be consented for treatment. The role of informed consent is to ensure that patients understand the purpose, benefits, risks, and all treatment options before deciding to accept or refuse treatment. Adequately informing patients and obtaining consent in regard to treatment is a specific legal requirement and an accepted part of good medical practice. Link to the NSW Health 2005 Consent to Medical Treatment ­ Patient Information PD2005_406 Patient Assessment All patients should have a general assessment at baseline and throughout their treatment according to treatment protocol requirements including: ■
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laboratory results, if blood parameters are abnormal notify medical officer baseline observations specific to the treatment protocol symptom and side effect allergy and drug reaction history performance status weight, height, body surface area (BSA) and ECOG status psychosocial screening Link to Assessment Tool ­ Antineoplastic Drug General Assessment Link to Eastern Cooperative Oncology Group (ECOG) Status Page 1 of 5
Resource Document - Safe Administration of Antineoplastic Drugs
Safe Handling Precautions Appropriate personal protective equipment (PPE) should be worn for administration of all antineoplastic therapy. Resource Document ­ Safe Handling and Waste Management of Hazardous Drugs Time Out Procedure All drugs MUST be checked at the point of administration by two appropriately trained and skilled registered nurses. Where a second nurse is not available an appropriately trained pharmacist or a medical officer can perform this function. 'Time Out' includes verification of the: ■
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right patient right drug right dose right route right time The medication order for antineoplastic drugs should present the treatment information in a clear, consistent and unambiguous manner and include all supportive therapies associated with the treatment protocol. The performance of these checks must be verified by signing and dating the medication chart and or the
'Time Out' procedure checklist by both health professionals. Link to Antineoplastic Drug Administration Timeout Checklist Link to NSW Health 2007 Correct Patient, Correct Procedure and Correct Site PD2007­079 30­Oct­2007 Oral Antineoplastic Drug Administration ■
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do not crush or break oral tablets or open capsules if a patient is unable to swallow, or if medication is to be administered by a percutaneous endoscopic gastrostomy (PEG) tube or a nasogastric tube, the pharmacist must be contacted for advice on alternative dose formulations capsules and coated tablets should be administered using chemoprotectant gloves and the 'non touch technique' full personal protective equipment (PPE) should should be worn when administering uncoated tablets ● link to Table of Oral Antineoplastic Drugs if the patient vomits within a few hours of taking the drug, do not repeat the dose ● inform the medical officer for further guidance if the patient forgets to take a dose it should be taken as soon as possible if it is within 12 hours of the missed dose. If it is more than 12 hours since the missed dose, skip the missed dose and continue usual dosing all tablets and capsules should be stored appropriately as directed by pharmacy all unused tablets and capsules should be returned to pharmacy Link to Clinical Procedure ­ Oral Antineoplastic Drug Administration Intramuscular and Subcutaneous Antineoplastic Drug Administration ■
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all drugs should be stored appropriately prior to administration as directed by pharmacy all syringes should be checked prior to use for any leakage or contamination DO NOT expel air from syringe select an appropriate site for administration ● if frequent injections are given, rotate the injection site appropriate personal protective equipment (PPE) should be worn by personnel administering antineoplastic drugs Page 2 of 5
Resource Document - Safe Administration of Antineoplastic Drugs
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patients should be monitored for signs and symptoms of a hypersensitivity reaction unused drugs should be returned to the pharmacy Link to Clinical Procedure ­ Intramuscular and Subcutaneous Antineoplastic Drug Administration Intravenous Antineoplastic Drug Administration ■
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all syringes and infusion bags should be checked prior to use for any leakage, cloudiness or signs of precipitation or contamination. Some preparation may require gentle agitation to mix prior to administration to ensure an even dispersion of drug in the diluent as medication can settle on storage. check protocols for specific requirements e.g. assessments, monitoring, pre­medications, anti­emetics or fluids prior to administering antineoplastic drugs all drugs should be stored appropriately prior to administration as directed by pharmacy unused drugs should be returned to the pharmacy appropriate personal protective equipment (PPE) should be worn by personnel administering antineoplastic drugs closed system intravenous administration sets with leur lock fittings should be used for administration of antineoplastic therapy Intravenous Cannula (IVC) ■
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it is recommended to use a newly sited cannula wherever possible ● vesicant drugs should be administered through a newly sited cannula where possible* ● for non vesicant drugs, the cannula should not have been in situ for more than 48 hours choose an appropriate IVC type and size for the type of treatment ● do not use a steel cannula if possible use a large vein in the middle of the forearm avoid cannulating the back of hand, joints and the antecubital fossa do not use the arm on the side of an axillary lymph node dissection avoid cannulating veins that have been recently used as there is an increased risk of leakage of the drug from the old site; use a different vein on the opposite limb. If this is not possible then a site in the same vein may be selected but it should be proximal to the previous puncture ensure the IVC is stabilised and secured with a transparent dressing to allow the site to be visualised ensure patency of the IVC: ● check for blood return when inserting the cannula ● check that no resistance is felt when injecting fluid into the cannula ● observe that the intravenous infusion flows freely once connected if the IVC is not patent or resistance is felt, a new IVC should be inserted Central Venous Access Device (CVAD) ■
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stabilise and secure the CVAD with a transparent dressing to allow the site to be visualised select an appropriate needle size for implanted venous ports (IVP) confirm the patency of the CVAD by withdrawing blood and then flushing with 5 to 10 mL sodium chloride 0.9% or other compatible fluid do not use if resistance is felt to the flow of fluid ­ refer to a senior nurse and medical officer During Intravenous Administration of Antineoplastic Drugs: ■
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monitor patient for signs and symptoms of hypersensitivity reactions the order of drug administration should be as follows (unless otherwise indicated by the specific treatment protocol): ● give vesicant drugs first ● followed by irritants with vesicant like properties ● then irritants ● and lastly neutrals Page 3 of 5
Resource Document - Safe Administration of Antineoplastic Drugs
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If there is more than one vesicant drug, the drug with the most harmful properties should be administered first e.g. anthracyclines followed by vinca alkaloids during the administration of a vesicant drug ● staff should remain at the patient's side during the entire administration ● vesicant drugs should be diluted during administration by injection into a side port of a fast running drip or via a minibag ● DO NOT inject against resistance ❍ if administration is via a CVAD, do not proceed without a full review of the CVAD and/or radiologic confirmation of patency ● DO NOT use a pump to administer ❍ administer by free flow using gravity ● check line patency and blood return regularly throughout the drug administration ● monitor the site for signs of extravasation or leakage if extravasation is suspected, STOP the infusion: ● inspect the IVC for blood return, and ● inspect the insertion site for signs of leakage or oedema educate the patient to immediately report symptoms such as pain, burning, stinging, swelling, or erythema during and after administration extravasation must be managed immediately to minimise tissue necrosis ■
● link to Resource Document ­Extravasation Management if any doubt do not proceed with administration, review and manage appropriately ■
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Link to Clinical Procedure ­ Antineoplastic Drug Administration by an Intravenous Cannula Link to
Clinical Procedure ­ Antineoplastic Drug Administration via a Central Venous Access Device Vincristine Administration Vincristine (a vinca alkaloid and vesicant) must only be administered intravenously. It has been associated with errors involving inadvertent administration by the incorrect route which has resulted in permanent disability and death. Link to
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Safety and Quality Council 2005. Safety Alert ­ Vincristine vincristine must be supplied in an infusion bag. The minimum recommended volume is 50 mL to be administered over 5 to 15 minutes distinctive warning labels must be placed on all vincristine preparations: "FOR INTRAVENOUS USE ONLY ­ Fatal if given by other routes" *NSW Health Policy Standard PD2012_003 "High Risk Medicines Management" recommends that a peripheral cannula used to administer vincristine shoud have been inserted within the last 24 hours. Post Administration ■
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Ensure administration of post therapy fluids and medications are given as per protocol requirements e.g. folinic acid rescue; antiemetics monitor and assess patients as per protocol requirements arrange relevant laboratory tests and provide patient with appropriate forms ensure an appointment for medical review and the next cycle of treatment is booked refer to community nurse if required: ●
Community Nurse Referral Form ensure patient has all discharge medications provide written instructions or access to information about the treatment administered including expected side effects, precautions to be taken and what to do in event of an adverse effects e.g. uncontrolled nausea and vomiting or severe diarrhoea provide emergency contact details for medical staff and treatment centre Documentation Document in the patient notes: ■
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patient and carer education patient assessment record of drug administration any adverse events and the interventions e.g. dose reductions patient referrals Disclaimer: This document reflects what is currently regarded as safe practice. While every effort has been made to ensure the accuracy of the contents at the time of publication, the Cancer Institute, NSW does not accept any liability, with respect to loss, damage, injury or expense arising from any such errors or omission in the contents of this work. Any reference throughout the document to specific pharmaceuticals and/or medical products as examples does not imply endorsement of any of these products. Page 4 of 5
Resource Document - Safe Administration of Antineoplastic Drugs
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Cancer Nurses of Australia. 2010. Position Statement on the Minimum Education and Safety Requirements for Nurses involved in the Administration of Drugs. Created: July 2003. Reviewed: April 2010. ­ Link to external article Clinical Oncological Society of Australia 2008. Guidelines for the Safe Prescribing, Dispensing and Administration of Cancer Chemotherapy November 2008 NSW Health. 2007. Medication Handling in NSW Public Hospitals. PD2007_077. NSW Department of Health. ­ Link to external article 2007. "ISOPP standards of practice. Safe handling of cytotoxics." J Oncol Pharm Pract 13 Suppl:1­81. ­ Link to external article Adams, S., Barrett, L., Brooks, S. et al 2007 "Central Venous Access Devices: Principles for Nursing Practice and Education". Cancer Nurses Society of Australia NSW Health. 2007. Correct Patient, Correct Procedure and Correct Site Policy. PD2007_079. NSW Dept of Health. 2007 ­ Link to external article Hadaway, L. C. 2004. "Preventing and managing peripheral extravasation." Nursing 34(5):66­67. ­ Link to external article Hadaway, L. C. and D. A. Millam. 2005. "On the road to successful I.V. starts." Nursing 35 Suppl On:1­14; quiz 14­
16. ­ Link to external article Wood, L. S. and S. M. Gullo. 1993. "IV vesicants: how to avoid extravasation." Am J Nurs 93(4):42­46. ­ Link to external article NSW Health. 2005. Consent to Medical Treatment ­ Patient Information. PD2005_406. NSW Department of health. ­ Link to external article Hadaway, L. C. 2004. "Preventing extravasation from a central line." Nursing 34(6): 22­3. ­ Link to external article Camp­Sorrell, D (eds) 2004. "Access device guidelines: recommendations for nursing practice and education" 2nd ed. Oncology Nursing Society. Pittsburgh. NSW Health. 2007. Infection Control Policy PD2007_36. NSW Department of Health 2007 ­ Link to external article Eisenberg.,S. 2010 Nursing Safety: Practice Safe Nursing with Oral Hazardous Drugs. ONS Connect January 2010 NSW Health Policy Standard "High Risk Medicines Management" PD2012_003 January 2012 ­ Link to external article The currency of this information is guaranteed only up until the date of printing, for any updates please check www.eviq.org.au ­ 03 Apr 2012 Page 5 of 5