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NORTH WALES CANCER NETWORK
DRAFT
GUIDANCE ON THE
MANAGEMENT OF CYTOTOXIC
CHEMOTHERAPY
December 2008
CONTENT
PAGE
1. Policy Statement
3
2. Purpose
3
3. Scope of Policy
3
4. Organisation and Responsibilities
3
5. Definitions
3
6. Facilities, Storage and Transportation
4
7. Personnel and Training
5
8. Safety
7
9.0 Prescribing
7
9.1 Electronic prescribing
8
10. Timing
8
11. Preparation and Labelling
9
12. Cytotoxic Waste
10
13. Cytotoxic Spillage
11
14. Administration of chemotherapy
11
14.1 Administration procedure
11
14.2 Record keeping
11
14.3 Verification Procedure
11
14.4 Consent
11
14.5 Pre-treatment assessment
12
14.6 Chemotherapy referral
12
15. Extravasation
12
16. Audit and External Assessment
12
17.0 Exceptional Circumstances
13
17.0 Administration of chemotherapy in non-essential areas
13
18. Policy Development
13
19. References
14
1. Policy statement
This policy is based upon the recommendations of a report by the Joint Council for Clinical
Oncology (1994) and is compliant with the following;

Department of Health Standards for Cancer Services (2001)

Manual of Cancer Services (2004) NHS Executive

National Cancer Standards (2005)

National Guidance on the Safe Administration of Intrathecal Chemotherapy (2008)

The Health and Safety at Work Act (1974)

The Health and Safety Executive Guidance on the Safe Handling of Cytotoxic
Drugs (2003)

Hazardous Waste Regulations (England and Wales), (2005)

Carriage of Dangerous Goods (Classification, Packaging and labelling)
Regulations (1996)
2. Purpose
This guidance is intended to safeguard patients and staff, by defining best practice for all
disciplines involved in cytotoxic chemotherapy. The guidance is not intended to be
prescriptive but to provide a framework of principles upon which local policies can be
based. However, any deviations from this guidance must be specified and justified in any
local policy.
3. Scope of policy
This document is primarily aimed at staff delivering chemotherapy for patients with
malignant disease, at in-patient, out-patient and community settings.
The guidance applies to;
 oral, intravenous, intra-arterial, intramuscular, subcutaneous, intravesical,
intravitreal, intrapleural and subconjunctival cytotoxic drugs.
 all staff involved in any aspect of cytotoxic chemotherapy within the organisation, for
example urology, dermatology, ophthalmic, haematology and oncology.
 the administration of other anticancer therapies for example Monoclonal Antibodies.
Intrathecal chemotherapy is within the scope of this policy but is controlled by a
separate policy in the organisation adhering to; A Guide to the Safe Handling and
Administration of Intrathecal Chemotherapy (WAG, 2008).
4. Organisational responsibilities
Responsibility for compliance with this policy lies with the appropriate Lead Clinician, Lead
Nurse and Manager identified and designated as such by the organisation.
5. Definitions
Cytotoxic chemotherapy throughout this policy refers to all drugs with direct anti-tumour
activity including conventional anticancer drugs, monoclonal antibodies, partially targeted
treatments and drugs such as thalidomide. It excludes hormonal treatment.
North Wales Cancer Network. Beryl Roberts. December 2008
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Management of cytotoxic chemotherapy includes prescribing, preparation, storage,
administration, transportation, safe handling and disposal.
Approved clinical areas are equipped for the administration of cytotoxic chemotherapy.
They may be either specialist wards or those on which cytotoxic drugs are an essential
part of the treatment of patients, but used less frequently.
In approved areas where the drugs are not used frequently, it may not be possible to
ensure that appropriately trained staff are available to administer cytotoxic drugs, in such
circumstances patients or staff should be moved as appropriate to ensure safe
administration.
Specialist wards or departments are those designated areas within the organisation
where cytotoxic chemotherapy is administered as part of everyday practice. These units
are equipped for the purpose and have staff trained to administer the drugs and to care for
patients who have received cytotoxic chemotherapy.
Approved chemotherapy protocols and regimens. Detailed written chemotherapy
protocols should be used for the management of all cancer sites treated by the
organisation. Protocols should include regimen/s and indication, drug doses and
scheduling, investigations, and dose modifications. Each protocol should be validated by
appropriate personnel and contain a date of validation and review. First and second line
treatment should be those approved for use in the Network Formulary.
6. Facilities, storage, packaging and transportation
In-patient cytotoxic chemotherapy is administered only in approved clinical areas where it
is an agreed part of, or whole of the activity of that ward or department.
Outpatient cytotoxic chemotherapy is administered in approved clinical areas where it is an
agreed part of, or whole of the activity of that ward or department.
The appropriate Lead Clinician, identified and designated as such by the organisation,
maintains a list of the approved clinical areas within their division. They will ensure that an
up to date list of approved clinical areas is available to the relevant wards and departments
including pharmacy.
All approved clinical areas must have a copy of the “Guidance for the Management of
Cytotoxic Chemotherapy available”.
All clinical areas must have access to a copy of the treatment protocols for the drug
regimens used and copies of procedures and equipment necessary for the management of
emergencies, such as cardiac arrest, anaphylaxis, extravasation of cytotoxic drugs and
spillage of cytotoxic drugs
All approved clinical areas must have a dedicated area within them for the storage and for
the organisation of chemotherapy before administration.
Patients receiving cytotoxic chemotherapy in the community should be given verbal and
written information on how to handle cytotoxic drugs appropriately (this may be included in
the treatment information provided to the patient). This information must include the safe
and appropriate storage of cytotoxic drugs in the home, safe disposal of cytotoxic waste;
North Wales Cancer Network. Beryl Roberts. December 2008
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safe transportation of cytotoxic drugs from hospital to home and administration techniques
if self-administering the drugs.
A patient information leaflet (PIL) should be provided with oral chemotherapy drugs. Refer
to Network and local guidance on oral anti-cancer medicines for further detail.
It is the responsibility of the prescriber to ensure a patient is capable of self-administering
oral chemotherapy in the community. If not capable e.g. due to disability such a blindness
or learning disabilities, the prescriber must ensure the patient has a support system in
place e.g. a family member who can administer, or a district nurse. If in any doubt, a risk
assessment should be carried out to ascertain whether treatment should be given, or not
given if appropriate arrangements for safe administration cannot be put into place.
All cytotoxic drugs should be packaged;
 to ensure any spillage is contained
 only use luer lock syringes
 be transparent to allow for identification and awareness of leakage
 identifying the hazardous nature of the contents
 offer UV protection if the contents are light sensitive
 indicate the storage requirements once received
Transportation of cytotoxic drugs should;
 utilise containers which provide adequate protection to both the drugs and the
environment
 identifying the hazardous nature of the contents
 indicate the storage requirements once received
 allow segregation of drugs for individual patients
For transportation involving a third party, e.g. porter, there should additionally be;
 tamper evident outer containers
 access to a spillage kit
 information on how to deal with a spillage
Take home oral cytotoxic chemotherapy should;
 be labelled with patients name, hospital number, name of drug, dosage, length of
treatment, instructions and date dispensed
 contain patient information leaflet
 identify the hazardous nature of the contents, where appropriate
 indicate the storage requirements once received
 offer UV protection if the contents are light sensitive
7. Personnel and Training
The training of staff in all aspects of cytotoxic chemotherapy must be undertaken by staff
trained and accredited to do so.
The Medical Director- or an individual identified by the Medical Director to act on his/her
behalf must ensure that arrangements are made for the training and assessment of
medical staff, to which the responsibility for prescribing of these drugs is delegated.
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The organisation must have a named Lead Nurse for chemotherapy who will oversee the
training and assessment of nurses involved in administration and checking of cytotoxic
chemotherapy.
The Chief Pharmacist in the organisation will ensure that a process is in place where
pharmacy staff who prepare, check or supply cytotoxic chemotherapy are trained and
assessed regularly.
The appropriate Clinical Director or Lead Clinicians, Lead Nurses and the Chief
Pharmacist will maintain up to date registers of accredited medical, nursing and pharmacy
staff respectively. The register will include details of the role the individual is accredited to
undertake (the registers are held in each area and do not form part of this policy).
A written record of the assessment must be maintained at both a personal and
organisational level.
Administration of cytotoxic chemotherapy by intravitreal, subconjunctival and ocular routes
will only be carried out by consultant ophthalmologists or specialist registrars accredited to
so. There should be separate local policies for these specialised procedures.
Doctors who administer intravenous cytotoxic chemotherapy must;

Have completed a training programme recognised by the organisation on the
administration of cytotoxic chemotherapy. This must include training specific to the
route of administration to be used.

Have had their competence in the administration of cytotoxic chemotherapy, by the
route of administration to be used, assessed by the designated assessor.
Registered Nurses who administer intravenous cytotoxic chemotherapy must;

Have completed a training programme recognised by the organisation in the
administration of cytotoxic chemotherapy

Work in an area where chemotherapy is given regularly, to maintain competency.

Have had their competency in the administration of cytotoxic chemotherapy
assessed annually, by the assigned assessor for the department.
Where administration involves the use of electronic, volumetric, syringe driver or
ambulatory infusion pumps, the nurse must be trained and accredited to use the pump in
accordance with the organisational requirements.
Nurses caring for patients who have received cytotoxic chemotherapy must be familiar
with the appropriate guidelines pertaining to the care of these patients.
Any medical, nursing or pharmacy professional assessed as not competent to practise
unsupervised must undergo further training as deemed necessary by their assessor. They
must then be re-assessed and deemed competent before being permitted to administer
further chemotherapy unsupervised. The Lead Clinician and the Lead Nurse and Chief
Pharmacist must be informed if a doctor or nurse is considered to be not competent.
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Every professional who administers chemotherapy must keep up to date with current
evidence and knowledge regarding chemotherapy administration. Every professional must
ensure that they are aware of any new chemotherapy protocol administered for the first
time (NMC, 2004).
Having been deemed competent, the onus in then on each individual to only give
chemotherapy they feel competent to administer as indicated in the Code of professional
conduct, standards for conduct, performance and ethics (NMC, 2004).
8. Safety
The COSHH Regulations (2002) require that monitoring or health surveillance should be
implemented if a risk cannot be totally eliminated. Most current methods for staff
monitoring are not suitable and produce results that are difficult to interpret, therefore
routine health surveillance is not recommended at present.
The adoption of safe handling techniques reduces the potential for exposure to cytotoxic
drugs significantly. Records of staff exposure to cytotoxics through spillage, splash or
needle-stick injury must be recorded on an Incident Report Form and the individual
referred to the Occupational Health Department within the organisation.
All staff handling cytotoxic drugs must be made aware of the risks in relation to pregnancy
and conception. This includes male and female staff of reproductive age, including those
at risk of occupational exposure through preparation/reconstitution, administration,
handling patient excreta/body fluids or cytotoxic waste. All staff must be made aware of the
importance of minimising exposure to cytotoxics at all times. Employees should notify their
managers as soon as possible if they are pregnant, trying to conceive or are breast
feeding. A New and Expectant Mother at Work Risk Assessment Form should be
completed in accordance with organisation’s Risk Assessment Policy and appropriate
action taken. The Occupational Health Department must be involved. Individuals should be
provided with all the information available to enable them to make an informed choice and
always be offered alternative duties if they choose not to work with cytotoxics at this time.
All staff involved in the care of patients receiving cytotoxic chemotherapy must challenge
colleagues, if, in their judgement, a protocol is either not being adhered to, or the actions
of an individual may cause a potential risk to a patient or colleague. Challenging a
colleague should not be seen as adversarial, but as an additional check to improve patient
safety.
9.0 Prescribing
The decision to treat a patient with cytotoxic chemotherapy should be made by the
Consultant and primary chemotherapy discussed at the relevant MDT.
Cytotoxic chemotherapy must be prescribed by a consultant, specialist registrar, staff
grade, associate specialist or non-medical prescriber trained to do so. Assurances around
the ability of prescribing personnel rest with the Lead Clinician identified by the
organisation as responsible for the service.
That Lead Clinician must be satisfied that the Prescriber is trained and competent to
prescribe chemotherapy in a manner that meets the requirements of this policy and any
local organisational policies relevant to the prescribing of medicines.
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Where possible there will be electronic prescribing of all cytotoxic chemotherapy. If this is
not feasible a recognised chemotherapy prescription sheet should be used, ideally a preprinted sheet and the pharmacy department must;

Hold a register of approved chemotherapy regimens used within the directorate as
included in the North Wales Cancer Network Chemotherapy Formulary. The
register must indicate a version number for each regimen, the date it was approved
and the date superseded or alternative version control method.

The departmental manager and the haematology/oncology pharmacist must ensure
that only the most up to date version of approved treatment regimens are stored in
pharmacy.

Copies of all approved prescribers’ signatures will be held in the pharmacy
department.

Non-formulary regimens and new drugs will only be issued when the Network
process of introducing new drugs has been followed.
 Regular use of regimens for first and second line therapy not in the Network
Chemotherapy Formulary should be discouraged. The pharmacy department
should record instances when the regimens are used and be able to provide this
information upon request to the Network.
9.1 Electronic prescribing
The electronic prescribing database is populated with approved protocols, which make up
the North Wales Cancer Network Chemotherapy Formulary. It is the responsibility of the
systems manager to maintain and update the database.
Each chemotherapy regimen must indicate a version number, the date it was approved
and the date it was superseded. Any amendment made to a chemotherapy regimen by the
system manager must be validated by another independent pharmacist (QA) and
consultant before final approval by the Clinical Director. Copies of all approved prescriber
signatures will be held in the pharmacy department.
Authorisation to proceed with the administration of parenteral cytotoxic chemotherapy can
be carried out by a validated member of the medical or nursing staff where blood
parameters are within acceptable limits and the patient is deemed fit for treatment.
10. Timing
Cytotoxic drug administration is undertaken during normal working hours in order to
ensure availability of experienced and senior medical and nursing staff and supporting
services, whenever possible.
Some chemotherapy regimens will require administration of drugs to continue overnight or
over the weekend. These regimens must be planned and started during working hours
unless clinically indicated.
North Wales Cancer Network. Beryl Roberts. December 2008
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11. Preparation and Labelling
All cytotoxic drug doses must be prepared in the pharmacy department.
Requests for cytotoxic doses should be submitted to the pharmacy at least 48 hours
before a dose is required. There will be an agreed cut-off time for each pharmacy cytotoxic
department for doses required the same working day, requests after this time will be
subject to availability of pharmacy and nursing staff. Requests made on the day of
treatment will also be subject to availability of nursing and pharmacy staff.
The organisation should have a system in place to provide urgent out of hours
chemotherapy.
The pharmacy will adhere to Medicines and Healthcare Products Regulatory Agency
(MHRA) requirements and with NHS standards for aseptic preparation as appropriate.
Preparation and supply are carried out under the supervision of an appropriate pharmacist
with relevant experience in aseptic services and oncology/haematology.
The preparation of cytotoxic chemotherapy is undertaken by pharmacy assistants,
pharmacy technicians or pharmacists who have received the appropriate training and have
been assessed competent.
A written record of the competency assessment is maintained at a personal and
organisational level.
The Chief Pharmacist is to be informed when pharmacy staff are accredited or lose
accreditation.
Labelling of all cytotoxic chemotherapy should include the following;
 Patient name and hospital number
 Date of preparation
 Name and dose of product
 Route of administration
 Expiry
 Batch number
 Storage conditions
 Wording that identifies the product as a cytotoxic drug
Labelling and dilution of vinca alkalods (vincristine, vinblastine, vindesine and vinorelbine)
for intravenous use must be in accordance with CMO (2008), prepared in an infusion bag
and administered over 5 minutes monitoring the patient throughout, and must be positively
labelled. The pharmacies must ensure labels have in addition to the above details a clear
warning of the consequence of administration by other routes- “For Intravenous Use
Only - Fatal if given by other routes”
12. Cytotoxic Waste
Any unused chemotherapy should be stored within the clinical area in a designated
location where the pharmacy staff can collect or the nursing staff can return to pharmacy
at the next available opportunity.
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Discontinued infusion bags containing residual fluid should remain connected to the
infusion set and clamped. The bag should then be treated as cytotoxic waste and disposed
of in an empty sharps bin.
Legislation requires the organisation to segregate hazardous waste from non-hazardous
waste. All cytotoxic drugs are classed as Hazardous waste and should be disposed of
according to the organisation’s policy on disposal of hazardous waste.
The ward or department manager is responsible for the cytotoxic waste generated during
the administration of cytotoxic drugs until the authorised waste collector or porter collects it
from the ward or department.
Responsibilities of the ward manager include;

To ensure adequate secure storage is provided for cytotoxic waste

To ensure cytotoxic waste is appropriately packaged, sealed, identified and labelled
as cytotoxic waste

To ensure cytotoxic waste is segregated from other clinical waste and special waste
at the point of production
Responsibilities of waste collectors and porters;

Internal transport and storage of cytotoxic waste – The authorised waste
collector/porter is responsible for the delivery of cytotoxic waste to a secure central
storage facility on site.

Consignment to Third Party for disposal – Where cytotoxic waste is to consigned to
a third party for disposal, the collector/porter is responsible for the completion of the
appropriate consignment note.
Responsibilities of the organisation’s Waste Manager include;

Ensuring trust waste collecting staff and external contractors, who collect waste
from wards and departments within the trust, are trained in the operation of this
policy and in the safe handling of cytotoxic waste.

To ensure a secure storage area is made available for the on site storage of
cytotoxic waste, following collections from wards and departments within the
organisation, prior to consignment to external contractors for transport and disposal.

Completion and archiving of documentation relating to the transport and disposal of
cytotoxic waste is maintained in line with current legislation.

During the selection and monitoring of external contractors for the transport and
disposal of cytotoxic waste, ensuring that contractors undertaking this activity are
licensed by the Environmental Agency to undertake these activities.
North Wales Cancer Network. Beryl Roberts. December 2008
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13. Cytotoxic Spillage
All staff involved in chemotherapy, or the collection and transport of cytotoxic waste,
should be familiar with the relevant organisational policies. Staff should be trained to deal
with cytotoxic spillage in accordance with this policy.
Cytotoxic spillage kits must be available to all staff involved in the
preparation/administration of chemotherapy or the collection and transport of cytotoxic
waste.
All spillage should be recorded on a Trust Incident Reporting form.
14.0 Administration of chemotherapy
14.1 Administration Procedure
All staff involved in administration of chemotherapy should be familiar with organisational
policy for administration of chemotherapy by all routes, for dealing with spillage, human
waste and extravasation.
14.2 Record keeping
Adherence with the organisation Policy for Medical Records is essential. Prior to each
cycle of chemotherapy, there should be treatment records of each of the following;
 The results of essential serial investigations applicable to that cycle (and prior to an
administration within a cycle, if applicable)
 Any dose modifications and whether or not they are intended to be permanent
 Any cycle or administration delays
 Any introduced support drugs
 An appropriate weight should be available
14.3 Verification Procedure
There should be a verification procedure, which is carried out before each physical
administration of chemotherapy, in accordance to the organisation Medicines Policy to
ensure that the following aspects are correct;
 Patients identification on prescription chart and on all labelled drugs
 Critical test results
 Regimen and individual drug identification
 Diluents and dilution volumes, and any hydration
 Supportive drugs have been given as per prescription
 Administration route and duration
 Cycle number
 The administration as per the schedule within the cycle
14.4 Consent
Written consent must be obtained before a regimen is commenced. If a further or different
regimen is used then a new consent form must be processed.
North Wales Cancer Network. Beryl Roberts. December 2008
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Adequate explanation of what treatment is being prescribed and potential side effects
should be given, supported with generic and specific written information.
The practitioner administering the first treatment must ascertain that the patient has given
informed consent and understands sufficiently the potential side effects to treatment and
completes the consent form accordingly. Adherence to the Trust Consent Policy is
essential.
The completed consent form should be evident in the patient’s medical or chemotherapy
notes and the patient should be given a copy.
14.5 Pre treatment assessment
Prior to administration of chemotherapy, by any route a pre treatment physical and
psychosocial assessment must take place and be documented in the patient’s medical
notes. If and when appropriate, the patients’ carer’s needs must be reviewed and support/
referrals made.
14.6 Chemotherapy Referral
There should be treatment record for each patient prior to the start of a course of
chemotherapy containing the following;
 Patient identification
 Weight, height, surface area
 Cancer type
 Treatment intention if possible to categorise (palliative, curative, neo-adjuvant,
adjuvant)
 Regimen and doses (including all cytotoxic chemotherapy drugs to be used and
elective essential support drugs other than antiemetics)
 Route of administration (oral, IV, IM, SC)
 Number of cycles intended
 Frequency of cycles and of administrations within a cycle
 Investigations necessary prior to starting the whole course
 Investigations to be performed serially during the course (to detect/monitor both
toxicity and response) and their intended frequency
 For palliative, curative and neo-adjuvant treatments, i.e. any treatment other than
adjuvant; the maximum number of cycles after which the response to treatment is to
be reviewed prior to continuing the course
 Attendance managed by agreed non-medical staff e.g. nurse led attendances
15. Extravasation
The organisation policy on Extravasation should be followed.
16. Audit and external assessment
All the above measures should be audited.
The Trusts’ waste disposal contractor is audited on a monthly basis by members of the All
Wales Clinical Waste Consortium (representatives from each of the Trusts in Wales), to
ensure that they are compliant with their PPC licence and that the Trusts’ duty of care is
North Wales Cancer Network. Beryl Roberts. December 2008
12
not compromised. All incidents involving the cytotoxic waste consigned for transfer to a
third part will be reported via the Trusts’ Adverse Incident Reporting System.
17.0 Exceptional circumstances
Occasionally, in emergencies, it is necessary to start cytotoxic chemotherapy outside
normal hours. The decision to do so must be made by the patient’s consultant. A risk
assessment must be undertaken and documented by the patient’s consultant.
The patient’s consultant must complete a Clinical Incident Report Form (IR1) so that the
frequency of these events can be monitored. The incident should be categorised as
“Other: chemotherapy outside normal hours”
17.1 Administration of chemotherapy in non-essential areas.
Occasionally it may be necessary to administer cytotoxic drugs to patients on approved,
but non-specialist wards, where there are insufficient suitably trained nursing staff.
It is the patient’s consultant’s responsibility to manage clinical risk and a risk assessment
must be undertaken and documented by the consultant.
This may include negotiating for the transfer of the patient to an area in which the drugs
can be administered by suitably trained staff or for suitably trained staff to come to the
approved area to administer drugs.
If the transfer of patients or staff is necessary, the patient’s consultant must complete a
Clinical Incident Report Form, so that the frequency of these events can be monitored. The
incident should be categorised as “Other: chemotherapy administration on non-specialist
area” or “Other: patient transferred for chemotherapy”, as appropriate.
Some departments use cytotoxic chemotherapy on an occasional basis. In this
circumstance, it may not be possible to maintain a sufficient number of nurses who are
trained, assessed and accredited to administer cytotoxic chemotherapy as described
above. An alternative is for the department to identify key nurse who can administer the
chemotherapy. The following conditions should apply:

The designated nurse/(s) should be the sole person performing this procedure.

Have completed an appropriate training programme recognised by the organisation
in the administration of named chemotherapy

Have had their competency in the administration of cytotoxic chemotherapy
assessed annually, by the assigned assessor for the organisation.
18. Policy development
Key personnel and departments have been consulted and have contributed to the
development of this Policy.
North Wales Cancer Network. Beryl Roberts. December 2008
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References
Administration of cytotoxic therapies by registered nurses: a guide to the issues involved.
(1999) Welsh Association of Chemotherapy Specialist Nurse Group.
Administering subcutaneous methotrexate for inflammatory arthritis. RCN Guidance for
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A Guide to the Safe Handling and Administration of Vince Alkaloids. CMO (WAG 2005,
2008)
A Guide to the Safe Handling and Administration of Intrathecal Chemotherapy CMO (WAG
2005, 2008).
Cancer Services in Wales – Publication of National Cancer Standards and the implication
for Commissioners and Providers, through the Cancer Networks. WHC (2005) 051
Environmental protection Act (1990)
Health and Safety at Work Act (1974)
Lisa Dougherty, Sara Lister, eds. The Royal Marsden Hospital Manual of Clinical Nursing
Procedures, 2004: Blackwell, London.
Nursing and Midwifery Council (2004) The NMC Code of professional conduct, standards
for conduct, performance and ethics. London; NMC.
National Guidance on the Safe Administration of Intrathecal Chemotherapy. (2001)
Department of Health. London
Royal College of Radiologists, London
Standard for Cancer Services (2001), DoH, London
Hazardous Waste Regulations (2005)
Safe Handling of Cytotoxic Drugs (2003) HSE Information Sheet MISC615, Health and
Safety Executive.
Quality Control in Cancer Chemotherapy: Managerial and Procedural Aspects (1994). The
Joint Council for Clinical Oncology, Royal College of Physicians and Royal College of
Radiologists, London.
North Wales Cancer Network. Beryl Roberts. December 2008
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