Chemotherapy Policy - Ipswich Hospital

Chemotherapy 

Policy 

Version 3.0 

Purpose: 

For use by: 

This document is compliant with 

/supports compliance with: 

To safeguard patients and staff by defining best practice for all 

disciplines involved in chemotherapy 

All staff involved in the prescription, dispensing, administration & 

disposal of anti-cancer cytotoxic drugs 

Care Quality Commission, Essential Standards of Quality and Safety 

(2009), Outcome 9 

NHS Litigation Authority Standards 

This document supersedes: Chemotherapy Policy Version 2, Registered Document 524 

Approved by: 

Medicines Management Committee 

Approval date: 28 October 2011 

Ratified by 

Patient Safety Committee 

Date Ratified 21 November 2011 

Implementation date: 1 December 2011 

Review date 1 November 2014 

In case of queries contact: 

Responsible Officer 

Business Unit and Department 

Archive Date ie date document no 

longer in force 

Date document to be destroyed: ie 10 

years after archive date 

Head Matron BU7 Ext 6954 / Bleep 606 

Clinical Support Services & Cancer, Oncology & Haematology/ 

Pharmacy 

To be inserted by Information Governance Department when this 

document is superseded. This will be the same date as the 

implementation date of the new document. 

To be inserted by Information Governance Department when this 

document is superseded. 

Registered Document 1005 Page 1 of 48 

Chemotherapy Policy v3.0 Implementation Date 1 December 2011

Version and document control: 

Version 

number 

Date of 

issue 

Change Description 

2.1 

Section Change/update 

1.1 

Oct 11 1.3 

3.1 

3.2 

3.2 

3.2 

3.3 

3.12 

3.2 

3.2 

3.3 

3.12 

3.12 

3.12 

3.12 

3.12 

3.14 

4.1 

4.1 

Dates updated, intravenous added 

PTC – Primary Treatment Centre added to definitions 

Consent in child health added 

Treatment plan copy in medical notes removed 

Paediatric prescribing added 

Text corrected 

Oncology/Haematology notes instead of Medical notes 

Prescriber responsible for : completing treatment plan with 

details 

The development of new or amendments to existing protocols 

and associated documents will be approved by QUAD, 

detailed in work instruction 

Deviation from protocol section rewritten 

Changes made to reflect paediatrics, specify Boxford 

Assessment Unit as are to administer chemo. Sentence to 

specify where teenage & young adults receive chemo 

Double checking of chemo – checker must have completed 

modules 1-4 of Anglia Cancer Network education package 

Addition of „e.g. holistic assessment‟ to final bullet point 

Added „IV‟ to bullet point 1 

Refer to Trust Identification (wristband) Policy 

Nurse responsibilities: Add history of toxicities and 

complications is documented 

Paragraph added for paediatrics re out of hours initiation and 

administration of chemo 

To update training and education requirements for paediatric 

nurses 

Training section updated in line with new Anglia Network 

Chemotherapy Core Education Package 

Author 

G Heard 

This is a Controlled Document 

Printed copies of this document may not be up to date. 

intranet for the latest version, destroy all previous versions. 

Please check the Trust 

Trust documents may be disclosed as required by the Freedom of Information Act 2000. 

Details about sharing this document with third parties are contained in Section 6 of this 

document. 

As part of the hospital‟s networking arrangements and sharing best practice, the hospital 

supports the practice of sharing documents with other organisations. However, where the 

hospital holds copyright to a document, the document or part thereof so shared must not be 

used by any third party for its own commercial gain unless this hospital has given its express 

permission and is entitled to charge a fee. 

Release of any strategy, policy, procedure, guideline or other such material must be agreed 

with the Lead Director or Deputy/Associate Director (for hospital -wide issues) or Business 

Unit/ Departmental Management Team (for Business Unit or Departmental specific issues). 

Any requests to share this document must be directed in the first instance to the Head 

Matron, Oncology/Haematology. 



CHEMOTHERAPY POLICY 

Summary 

The policy is intended to safeguard patients and staff, by defining best practice for 

all disciplines involved in the process of chemotherapy treatment. 

The prescribing of chemotherapy including the responsibilities of the prescriber, 

authorization of protocols and the details required on the prescription are stated within 

the policy. 

All parenteral cytotoxic medicines will be dispensed by pharmacy and issued under the 

supervision of an appropriately accredited pharmacist. 

Vinca alkaloids will be dispensed in accordance with NPSA Rapid Response Report 

004. 

All healthcare personnel who may be involved in the handling of cytotoxic drugs must be 

aware of the requirements for health and safety. The policy details the requirement for 

personal protection and action to be taken in the event of spillage. 

Only nurses or doctors, who have received appropriate training and have been assessed 

as competent, may administer systemic anti cancer therapy chemotherapy drugs. This 

should only be given within the Woolverstone Day Unit, Chemotherapy outreach clinics, 

Somersham Ward and the Paediatric department. 

The details with regard to bolus and infusional administration must be followed in all 

clinical areas to minimise any potential risk to the patient. 

Extravasation is a major risk when administering chemotherapy. The details contained 

in the policy must be followed and appropriate records completed. 

The prescribing and dispensing of oral anti-cancer chemotherapy must be carried out 

and monitored to the same standards as those for injectable therapy. 

(NPSA/2008/RRR001). All oral anti-cancer medicines must be prescribed in the context 

of a written protocol and treatment plan using an approved proforma and a copy filed in 

the medical notes. 

Prescriptions for oral chemotherapy drugs for oncology or haematology patients must 

state clearly for each course of treatment the dose, frequency of administration, intended 

start date, duration of treatment and where relevant the intended stop date. 

An appropriately trained and accredited pharmacist must screen all prescriptions before 

dispensing. All pharmacy staff who are, or could be, involved with dispensing oral 

anticancer drugs must have access to full copies of the relevant protocols. 

If a patient, member of staff or visitor is involved in a spillage of cytotoxic drugs or 

potentially contaminated patient waste the detailed procedures contained within the 

policy must be followed. 

This policy describes the competency and training requirements for Oncology & 

Haematology Nursing staff. Other directorates should use the policy to determine the 

level of competence required within their specialty. 



Contents 

1.1 Policy Statement and Rationale ................................................................................... 6 

1.2 Key Principles .............................................................................................................. 6 

1.3 Definitions .................................................................................................................... 7 

SECTION 2 – DUTIES AND RESPONSIBILITIES ................................................................. 7 

2.1 Senior Managers ......................................................................................................... 7 

2.2 Department Managers ................................................................................................. 7 

2.3 Employees ................................................................................................................... 8 

SECTION 3 – CHEMOTHERAPY POLICY ............................................................................ 8 

3.1 Consent for treatment (Oncology/haematology department) ........................................ 8 

3.2 Prescribing .................................................................................................................. 9 

3.3 Deviation from treatment algorithms and regimen protocols ...................................... 11 

3.4 Purchasing, Receipt and Storage in Pharmacy .......................................................... 12 

3.5 Screening and dispensing of prescriptions by pharmacy ........................................... 12 

3.6 Preparation and Dispensing ....................................................................................... 13 

3.7 Supply of Cytotoxic drugs .......................................................................................... 14 

3.8 Transportation ........................................................................................................... 16 

3.9 Storage in clinical areas ............................................................................................. 16 

3.10 Health and Safety ...................................................................................................... 16 

3.11 Venous Access .......................................................................................................... 18 

3.12 Administration ............................................................................................................ 19 

3.12.1 Administration of Intravenous Chemotherapy ..................................................22 

3.12.2 Intravenous infusional chemotherapy ..............................................................23 

3.12.3 Subcutaneous chemotherapy ..........................................................................24 

3.12.4 Intramuscular chemotherapy ...........................................................................25 

3.12.5 Intravesical administration ...............................................................................25 

3.12.6 Intrapleural administration Procedure ..............................................................27 

3.12.7 Intraperitoneal administration ..........................................................................28 

3.13 Extravasation ............................................................................................................. 29 

3.13.1 Diagnosis ........................................................................................................29 

3.13.2 Classification of cytotoxic drug ........................................................................30 

3.13.3 Intervention and Treatment .............................................................................33 

3.13.4 Hyaluronidase and saline flush out technique .................................................34 

3.13.5 Vesicant anthracycline extravasation and dexrazoxane ..................................34 

3.13.6 Plastic surgeon review ....................................................................................35 

3.13.7 Follow up care .................................................................................................35 

3.13.8 Documentation ................................................................................................35 

3.14 Out-of-hours initiation and administration of chemotherapy ....................................... 36 

3.15 Ambulatory and home chemotherapy treatment ........................................................ 36 

3.16 Oral chemotherapy preparations ................................................................................ 37 

3.16.1 Principles ........................................................................................................37 

3.16.2 Prescribing and administration of oral cytotoxic medication in non-oncology 

areas 40 



3.17 Disposal of cytotoxic waste ........................................................................................ 41 

3.17.1 Part used doses ..............................................................................................41 

3.17.2 Used disposal equipment ................................................................................41 

3.17.3 Patient Waste ..................................................................................................42 

3.18 Personal accidents and spillages ............................................................................... 42 

3.18.1 Skin contamination ..........................................................................................42 

3.18.2 Eye contamination ...........................................................................................43 

3.18.3 Needlestick injury ............................................................................................43 

3.18.4 Spillage ...........................................................................................................43 

SECTION 4 – TRAINING AND EDUCATION .......................................................................44 

4.1 Medical and Nursing Staff .......................................................................................... 44 

4.1.1 Oncology and Haematology Department .........................................................44 

4.1.2 Child Health ....................................................................................................45 

4.2 Pharmacy Staff .......................................................................................................... 45 

4.2.1 Handling ..........................................................................................................45 

4.2.2 Preparation .....................................................................................................46 

4.2.3 Clinical Screening of Chemotherapy Prescriptions ..........................................46 

4.2.4 Clinical screening and dispensing of Oral Chemotherapy Prescriptions ..........46 

4.3 Domestic Staff ........................................................................................................... 46 

4.4 Portering Staff ............................................................................................................ 46 

SECTION 5 – DEVELOPMENT AND IMPLEMENTATION INCLUDING DISSEMINATION ..46 

SECTION 6 – MONITORING COMPLIANCE AND EFFECTIVENESS .................................46 

SECTION 7 – CONTROL OF DOCUMENT INCLUDING ARCHIVING ARRANGEMENTS ..47 

SECTION 8 – SUPPORTING COMPLIANCE AND REFERENCES .....................................47 



SECTION 1 - INTRODUCTION 

1.1 Policy Statement and Rationale 

The Ipswich Hospital NHS Trust is committed to ensuring the safe prescribing, handling, 

dispensing and administration of chemotherapy. 

Treatment with chemotherapy is often a complex process and concerns about safety and 

quality of chemotherapy services have been highlighted by the National Chemotherapy 

Advisory Group report (Aug 2009) and a report of the National Confidential Enquiry into 

Patient Outcome and Death “For better or Worse” (Nov 2008). The Manual for Cancer 

Services (June 2011) sets out measures for clinical chemotherapy services and this policy is 

key to ensuring compliance with these measures. 

The handling and administration of cytotoxic drugs is potentially hazardous to both the health 

care professionals involved in their preparation and administration, and to the patients 

receiving them. While the risks to patients are, in the main, well documented and can be 

balanced against the clinical benefits, the risks to health care staff are largely theoretical. It 

is therefore prudent, with the present state of knowledge, to take every reasonable 

precaution to protect staff from unnecessary exposure. In addition the clinical use of these 

agents is not without patient safety risk and needs due diligence by all involved with their 

use. 

The policy aims to minimise these risks by promoting the safe prescribing and administration 

of chemotherapy and the safe handling of cytotoxic drugs. It should be read in conjunction 

with other relevant policies. 

The policy applies to the prescribing, preparation, dispensing and administration of all anticancer 

therapies used in the treatment of malignant disease in adult patients (with the 

exception of hormone treatments). Principally the guidance relates to systemic anti cancer 

therapy, however, the guidance regarding the storage, preparation, transportation, handling 

and administration of cytotoxic drugs applies across the Trust and regardless of the 

indication for use. 

It must be recognised that some intravenous and oral anti-cancer medicines are also used 

for non- cancer indications e.g. Methotrexate for rheumatoid arthritis, and pose similar risks 

to the patient. 

This document does not cover the practice of intrathecal chemotherapy. Please refer to The 

Ipswich Hospital NHS Trust Intrathecal chemotherapy policy and national guidance. 

1.2 Key Principles 

This policy is intended to safeguard patients and staff, by defining best practice for 

all disciplines involved in the process of chemotherapy treatment. 

Systemic anti cancer therapy within the Ipswich Hospital NHS Trust is provided by a 

multidisciplinary team in which doctors, specialist nurses and pharmacy staff work to 

approved protocols to provide integrated care both within the hospital and the 

community. 

If there is a clinical reason to deviate from this policy the rationale must be documented in 

the medical notes and signed by the relevant Consultant. The entry should be countersigned 

by the Chemotherapy lead, Principal Pharmacist for Oncology / Haematology and the lead 



chemotherapy nurse (or their deputies). Deviation from this policy should be reviewed every 

three months by the Head Matron and Principal Pharmacist and reported to the 

Chemotherapy Working Group and Cancer Network if required. 

1.3 Definitions 

Acronym Full Form 

AUC Area under (the) curve 

CNS Central Nervous System 

MHRA Medicines and Healthcare Products Regulatory Agency 

PIL Patient Information Leaflet 

QUAD Quality Assurance of Drugs 

TTA Drugs To Take Away 

COSHH Control of Substances Hazardous to Health 

IHNHST 

PTC 

Ipswich Hospital NHS Trust 

Primary Treatment Centre 

PPE Personal Protective Equipment 

MDT Multidisciplinary Team 

BMI Body Mass Index 

NMC Nursing and Midwifery Council 

GFR Glomerular Filteration Rate 

GP General Practitioner 

DoH Department of Health 

SVC Superior Vena Cava 

UKCCSG UK Children‟s Cancer Study Group 

IV 

Intravenous 

CVAD Central Venous Access Device 

VIP Visual infusion phlebitis 

FY2 Foundation Year 2 

BCG Bacillus Calmette-Guerin 

MMC Medicines Management Committee 

POD Patient Own Drugs 

SECTION 2 – DUTIES AND RESPONSIBILITIES 

The duties & responsibilities of different staff groups in relation to the safe prescribing, 

administration and handling of chemotherapy is outlined below. 

2.1 Senior Managers 

Designate responsibility for the implementation and maintenance of local policies and 

policy for the safe administration of chemotherapy and the handling of cytotoxic drugs. 

Ensure that all managers and supervisory staff are familiar with, and adhere to the 

Ipswich Hospital NHS Trust (IHNHST) chemotherapy policy. 

2.2 Department Managers 

Ensure that all relevant staff are fully familiar with the IHNHST Chemotherapy policy and 

the IHNHST Intrathecal chemotherapy policy, and that they are properly trained in, and 

comply with, all policies and procedures. 

If cytotoxic drugs are to be prescribed / administered in areas outside of the 

Woolverstone Wing department managers should ensure a risk assessment is 

undertaken and staff are competent to undertake the task. 



Ensure that staff that are pregnant, breastfeeding or trying to conceive, are not 

expected to be directly involved in the administration of cytotoxic drugs. 

Ensure that appropriate and properly maintained facilities and equipment are available to 

all staff handling cytotoxic drugs. 

Ensure that the service is reviewed against the current COSHH regulations with an 

authorised Trust COSHH advisor. 

2.3 Employees 

Ensure that all safety requirements according to the IHNHST Chemotherapy Policy are 

followed. 

Report all untoward incidents via the Trust risk management reporting system. 

Actively participate in training programmes provided. 

Inform managers if they are pregnant, breastfeeding or trying to conceive. 

SECTION 3 – CHEMOTHERAPY POLICY 

3.1 Consent for treatment (Oncology/haematology department) 

All staff should familiarise themselves with the Ipswich Hospital NHS Trust 

Consent Policy, the Good Practice in Consent implementation guide (DOH 2001) 

and 12 Key Points on consent: the law in England (DOH 2001). 

Information given by all health care professionals, both verbal and written, should 

be documented in the Patient‟s notes and recorded on the consent form. 

All patients receiving chemotherapy should be fully informed of their treatment and must 

have given consent. 

Consent form 3 (where consciousness is not impaired) is used for consenting to 

chemotherapy within the Oncology and Haematology Directorate. 

A copy of the completed form should be kept with the chemotherapy chart until the 

course of chemotherapy, that the consent form relates to, is completed. 

The specific chemotherapy regimen should be documented on the consent form. 

If a change in chemotherapy regimen is necessary, patients should be re-consented, 

after having received regimen specific details. This should again be documented as 

before. 

Consent may be taken by Medical Staff or appropriately trained nursing staff. 

Nursing staff able to take consent for chemotherapy must meet all of the 

following criteria: 

o Have attended an approved consent study day. 

o Be chemotherapy competent (see section 4). 

o Be aware of their own knowledge and limitations and work within their 

own competence 

o Be working at Band 6 level or above. 

The clinician taking consent should complete the entire form with the patient and not 

complete in advance leaving the patient to sign at a later date. 



It is the administering nurse‟s responsibility to ensure that the consent form has 

been signed by the patient and to reconfirm consent immediately prior to 

treatment. 

If the consent form cannot be located prior to commencing the next cycle of 

treatment the administering nurse should refer to the patient‟s notes for 

information regarding the consent process. If there is no documented evidence of 

consent being taken the patient should be re consented. 

In Child Health a copy of the consent for treatment from the PTC (usually Addenbrooke‟s 

Hospital) should be kept in the patient‟s notes and checked prior to chemotherapy 

administration, with documented discussion. 

3.2 Prescribing 

The decision to treat a patient with chemotherapy for a cancer indication should be made 

by a consultant, and the patient should be discussed at an appropriate Multidisciplinary 

Team Meeting (MDT). 

For chemotherapy treatments within the Oncology / Haematology Directorate a 

chemotherapy treatment plan (CH/FORM/7) should be completed and a copy placed in 

the Oncology & Haematology notes . Prescriptions without an accompanying treatment 

plan will be referred back to the prescriber. 

Only appropriately qualified and competent Consultant Oncologists, Haematologists, 

Staff grade / Specialist Registrars in training for greater than three months or clinical 

assistants may initiate and prescribe systemic anticancer therapy. 

Only Paediatric Oncologists at a PTC can initiate systemic anticancer therapy and 

prescribe first cycles of Chemotherapy. 

First cycles must be countersigned by a Consultant. 

Prescribing of second or subsequent courses may be delegated to FY2 Doctors, but only 

if there are clear written instructions available, in the form of a recognised protocol or 

entry into the patients‟ medical notes. If modifications of doses are required, the 

Consultant or Specialist Registrar must document this in the medical notes. 

For Paediatric oncology patients; chemotherapy should only be prescribed by a 

Paediatric Oncology Consultant or their deputy (as listed on the Paediatric competency 

register). Except for first cycles emergency chemotherapy may be prescribed by another 

Paediatric Consultant or Specialist Registrar and the prescription faxed to the PTC to be 

checked. This is only to be done in agreement with the PTC and chemotherapy should 

not be administered until confirmation has been received. 

The prescriber is responsible for: 

Ensuring the patient is fully informed of their treatment and has given consent. 

Ensuring that all relevant investigational parameters, as outlined in the individual 

protocols have been checked and that the patient is fit to receive treatment and 

ensuring any medication affecting chemotherapy has been considered. 

Selecting the appropriate protocol. 

Ensuring that the body surface area calculations, where relevant, are correct, and 

have been made using a recent weight. If patients are 30% over their ideal body 



weight, or the body mass index (BMI) is greater than 30, the need for dose reduction 

or dose capping should be considered. 

Ensuring accurate dosing. A maximum of a 5% variance (according to protocol 

dosages) in dosage calculation is permitted. 

A Treatment plan should be completed to include performance status, relevant 

previous medical history, previous chemotherapy history and frequency of medical 

review. 

Prescribing all chemotherapy and supportive therapies including antiemetics and 

hydration. 

Ensuring that maximum cumulative doses of anthracyclines and bleomycin have not 

been exceeded. 

Specifying the route of administration, and for parenteral doses, the duration of 

infusion on the prescription, if necessary. 

Ensuring there is an appropriate interval between treatments, as defined by the 

protocol. 

If a patient is to be treated with a chemo-radiation protocol, it is essential that the 

prescriber makes this clear on the prescription and treatment plan, and notifies the 

relevant nursing and/or pharmacy staff. 

Wherever possible, chemotherapy should be initiated during normal working hours when 

access to specialist staff is more likely to be available. Only in exceptional circumstances 

should chemotherapy be initiated outside of normal working hours. See section 3.14 for 

further details. 

Prescriptions for chemotherapy must be clearly written with no amend mends. Verbal 

messages for chemotherapy are not permitted. Outpatient prescriptions should include 

the name of the patient, hospital number and address. 

Prescriptions that are not clear will be returned to the prescriber / Consultant. 

All new chemotherapy protocols in routine use should be authorised by the 

Oncology / Haematology Quality Assurance of Drugs (QUAD) group. In exceptional 

circumstances the chemotherapy lead or Chair of the Oncology / Haematology QUAD 

group may authorise regimens and report at the next QUAD meeting. Existing protocols 

which have been reviewed may be authorised by the Chair of the Oncology / 

Haematology QUAD group or the chemotherapy lead. All authorisation of protocols 

should correspond with the Network Regimen list located on the intranet. 

Regimen protocols and pre printed prescription sheets are available on the intranet to 

be printed off and filed as a combined document in the patient‟s chemotherapy 

folder, with the current or most recent course topmost. 

Prescriptions for chemotherapy must be complete, clear and simple to follow. Each 

prescription should contain the following: 

Date prescribed. 

Patient name, date of birth, and hospital number (address for out-patient 

prescriptions). 

Patients weight, height, body surface area where relevant. 

For carboplatin prescriptions, uncorrected GFR (Glomerular Filtration rate)should be 

stated for adult patients. 

Consultant name. 

Regimen name or clinical trial name. 

Cycle or course number. 



Name of drug - use approved generic drug names; no abbreviations. 

The individual dose in mg (milligrams) or units, and target AUC for carboplatin. 

The frequency per day and the number of days of treatment. 

Route of administration (abbreviations are not acceptable, for example 

intraperitoneal or intrapleural must be written in full). 

For infusions, details of diluent and volume. 

Duration of infusion and any other administration instructions. 

Starting dates (and times when appropriate). 

Antiemetics, hydration and any additional drugs as defined by the protocol. 

Reason for any dose modifications. 

Start and stop dates where applicable. 

At the end of a planned regimen the current prescription needs to be clearly marked as 

completed by drawing a line through the current chemotherapy record card. The number 

of cycles completed and the end date should be entered onto the chemotherapy 

treatment plan (CH/FORM/7). 

After the final cycle is given in a course, the prescriber should ensure that there is a 

treatment record for each patient that states whether the course was completed or not. If 

the course was not completed, the reasons for cessation should be documented. For 

completed courses of non-adjuvant treatment, a reference to the response should be 

included. This information will be documented in the medical notes. 

If a new or amended regimen is to be prescribed a new chemotherapy treatment plan 

(CH/FORM/7) should be completed and a new chemotherapy record card commenced. 

3.3 Deviation from treatment algorithms and regimen protocols 

Treatment algorithms and the associated chemotherapy regimen are approved by the 

Anglia Cancer Network. Wherever possible treatment should be prescribed according to 

these documents however there may be exceptional circumstances where a consultant 

wishes to treat a patient with a regimen not described within the relevant treatment 

algorithm. 

The definition of “deviation” from both algorithms and protocols is defined in the “Anglia 

Cancer Network policy for the Management of Algorithm Deviations” (Version 1 Sept 

2011) 

The Development of new or amendments to existing protocols and associated 

documents will be approved by QUAD, detailed in work instruction. 

Application for regular use of a new protocol should be made initially by application to the 

Oncology & Haematology QUAD and then to the Network SACT Group. 

Deviations from the approved algorithms and regimen protocols will be recorded and 

reported to the network as stated in the “Anglia Cancer Network policy for the 

Management of Algorithm Deviations”. This report will also be presented to the QUAD 

meeting on a regular basis. 

In the rare event that the proposed protocol is deemed inappropriate, pharmacy 

will be informed by the Chair of QUAD not to supply that regimen and the relevant 

consultant informed. Caveats may be placed on use due to resource implications. 



If a deviation from an approved algorithm/protocol is to be used the Consultant must 

document the intended regimen in the patient‟s notes and prescribe the regimen. A form 

detailing the nature and reason for the deviation must be completed and placed within the 

patients chemotherapy folder. This must be completed in full prior to the commencement 

of treatment. 

Deviations from the approved algorithm and regimen may not be funded and therefore a 

source of funding must be approved (e.g cancer drugs fund, individual patient funding) 

before a patient is booked to commence therapy. 

The “off protocol” prescription must be signed by a Consultant Haematologist / Oncologist 

for each course of treatment. 

Unauthorised regimens for Paediatric Oncology patients should only be used at specific 

request and under the guidance of the PTC 

3.4 Purchasing, Receipt and Storage in Pharmacy 

The purchasing, receipt and storage of chemotherapy drugs in pharmacy is carried out in 

accordance with standard operating procedures by the Pharmacy Department. The 

pharmacy will ensure the effective control of the quality of these products. 

When purchasing cytotoxic drugs, risk assessments should be carried out in line with the 

Trust Purchasing for Safety Guideline as appropriate, to ensure that appropriate products 

are used. For example, wherever possible blister packed capsules or tablets are 

preferable to loose preparations, and products in vials would be preferable to ampoule 

formulations. 

Access to cytotoxic agent storage areas in pharmacy must be limited to authorised staff. 

All such storage areas will be clearly labelled with cytotoxic warnings. 

Main stocks of cytotoxic drugs will be held in the Pharmacy Department, under 

appropriate conditions. 

Clinical trial supplies of chemotherapy drugs should be kept separate from main stocks in 

pharmacy. 

Chemotherapy drugs are not available as ward stock. They should always be dispensed 

for individual patients. 

Cytotoxic drugs must be stored separately from other drugs. 

Storage must be designed in a manner that will prevent containers of cytotoxic agents 

from falling. 

Cytotoxic spillage kits should be available in all areas where cytotoxic drugs are stored. 

Damaged cartons of cytotoxic agents are to be discarded into a rigid sharps box. These 

should be labelled as cytotoxic waste and dealt with as in Section 3.17 If there is any 

contamination of the area or personal exposure to cytotoxic material, refer to Section 

3.18. 

3.5 Screening and dispensing of prescriptions by pharmacy 

An appropriately trained and accredited pharmacist must clinically screen and validate all 

prescriptions for all oral and parenteral chemotherapy. 



Prior to the preparation of a drug the pharmacist must verify the treatment plan and 

prescription according to the protocol or treatment regimen, clarify and resolve any 

discrepancies and check that: 

The appropriate protocol has been selected, with correct sequencing. 

All relevant investigational parameters such as complete blood counts, renal 

and hepatic function, as outlined in individual chemotherapy protocols, are 

reviewed and drug doses modified where necessary 

The body surface area calculations are correct. If patients are 30% over their 

ideal body weight, or the body mass index (BMI) is greater than 30, the 

pharmacist will contact the prescriber and discuss possible implications and 

the need for dose reduction or dose capping. 

An accurate dose has been prescribed. A maximum of a 5% variance 

(according to protocol dosages) in dosage calculation is permitted. 

Dose modifications to previous treatments are maintained if appropriate. 

All chemotherapy drugs and supportive therapies including antiemetics have 

been prescribed. 

Ensure that maximum cumulative doses of anthracyclines / bleomycin have 

not been exceeded. 

The route of administration and the duration of infusion have been specified 

on the prescription. 

The volume and diluent of infusion is appropriate with respect to the patient, 

protocol and pharmaceutical stability. 

There is an appropriate interval between treatments. 

If the prescription is for a new chemotherapy protocol or is „off protocol‟, the 

oncology/haematology pharmacist must discuss the case with the responsible consultant. 

A copy of an original paper from the responsible consultant detailing the protocol should 

be obtained. For further details, refer to section 3.3. 

Discrepancies exceeding plus or minus 5% of the dose, calculated according to the 

patient's treatment plan, must be clarified with the doctor. 

The pharmacist will resolve any discrepancies identified with the prescribing doctor prior 

to dispensing the medication(s). The actual prescription will be amended and any 

changes will be communicated to other team members as appropriate. The pharmacist 

will complete documentation of the discrepancy and the resolution. 

The pharmacist performing the clinical screening will document that the prescription is 

approved for preparation on the appropriate form. 

3.6 Preparation and Dispensing 



Dispensing and preparation of cytotoxic agents must take place in Pharmacy in 

accordance with Standard Operating Procedures. 

Preparation of parenteral cytotoxic agents must take place in isolators situated in a 

specifically controlled and monitored environment. The equipment must be certified at 

least annually. 

All pharmacy staff preparing cytotoxic agents will follow the Ipswich Hospital NHS Trust‟s 

pharmacy procedures. 

To facilitate drug preparation, changes to a previously written prescription may be made 

by an oncology or haematology pharmacist upon verbal confirmation from a doctor. Any 

changes on the prescriptions should be appropriately annotated by the pharmacist or 

prescriber. 

Appropriately trained and accredited pharmacy staff are responsible for the accurate 

preparation, documentation, labelling, determining and allocating the correct expiry date 

and time and storage conditions for a chemotherapy dose. 

The pharmacist performing the final product check will ensure correct documentation, 

computer entry, ensure appropriate order preparation, dispense and release the 

medication for the patient. 

The cytotoxic drug preparation service is open Monday to Friday 09.00 to 17.00 (except 

bank holidays). 

Whenever possible, all cancer chemotherapy should be initiated, and as much as is 

feasible, administered within normal working hours. However, there are some 

exceptional circumstances as outlined in section 3.14 where chemotherapy may need to 

be initiated and administered out of hours. If this is required the on call pharmacist 

should be contacted as soon as possible. 

In situations such as expired doses or split infusion bags, for patients who are receiving 

ongoing chemotherapy treatment regimens, contact the on call pharmacist for advice. 

3.7 Supply of Cytotoxic drugs 

Cytotoxic drugs are supplied as follows: 

Bolus IV, IM or SC doses 

Intravenous infusions 

Bladder instillation 

Intrapleural 

Intraperitoneal 

Tablets & capsules 

Oral liquids 

Topical 

in labelled Luer-locked syringes 

in sterile labelled bags of infusion fluid or 

appropriate device/ambulatory pump 

in labelled 50ml Luer-locked syringes, or a 

commercially available closed system device 

in labelled Luer-locked syringes 

In labelled Luer-locked syringes or infusion 

bags 

in clearly labelled bottles or cartons 

in clearly labelled bottles 

in clearly labelled tubes, ointment jars, 

dropper bottles or original packs 

The following details should also be stated on the parenteral preparation label: 

Generic drug name 

Amount of drug in container (in milligrams, grams or units) 



Infusion solution (including volume) 

Route of administration 

Patient name 

Hospital Number 

Ward 

Batch number 

Expiry date and time 

Storage conditions 

Warning: Cytotoxic Drug 

Name and address of pharmacy department 

Labels for Cytotoxic Tablets, Capsules and Oral Liquids. The following details should also 

be stated on the preparation label: 


Strength of tablets or capsules, or concentration of oral liquid 

The number of tablets / capsules in the container, or volume of liquid 

Patient name 

Full directions and an indication of length of treatment 


Warning: Cytotoxic Drug / Handle with Care 


Labels for Topical Preparations. The following details should also be stated on the 

preparation label: 


The strength of the cream/ointment or concentration of topical liquids 

The quantity of the preparation (either weight for creams or ointments, or volume 

for topical solutions). 

Patient name 

Full directions and an indication of length of treatment 

Expiry date where appropriate 


Warning: Cytotoxic Drug 

For external use only 


All vinca alkaloids will be labelled in large, bold font “FOR INTRAVENOUS USE ONLY – 

FATAL IF GIVEN BY ANY OTHER ROUTE” 

ALL Vinca alkaloids for adults will be supplied in 50ml minibags in accordance with NPSA 

safety alert (NPSA 2008 / RRR 004 Using Vinca Alkaloid Minibags). 

For patients under the age of 10 years, vinca alkaloids may be diluted to a maximum 

concentration of 0.1ml/ml and dispensed in at least a 10ml luer-lok syringe. The 

requirement for a smaller volume than 20ml MUST be specified by the prescriber. 

For children over the age of 10 years Vincristine will be diluted to 20mls and supplied in a 

50ml syringe. 

All Vinca Alkaloids will be packed into a yellow outer bag printed with the above 

warnings. 



3.8 Transportation 

Prepared cytotoxic agents must be transported in designated transport bags or boxes. 

These should be sturdy, secure and leak-proof and should be clearly labelled: 

CYTOTOXIC DRUGS - HANDLE WITH CARE. Additional precautionary labels should be 

added to the containers and the transport boxes as appropriate 

All Trust staff involved in the transportation of cytotoxic drugs must be trained to follow 

the Cytotoxic Spillage procedure. 

Pneumatic tubes must not be used for transporting cytotoxic agents (with the exception of 

oral tablets / capsules). 

If damaged or leaking cytotoxic products are received by clinical areas, the receiver 

should put on gloves and an apron, and place the damaged product into a leak proof 

container. This should be immediately labelled and returned to pharmacy, or disposed of 

appropriately on the ward/clinic as described in section 3.17 

Cytotoxic drugs that are to be transported outside of the hospital should be placed in 

sturdy, leakproof transport boxes. They should be clearly labelled as „Cytotoxic – handle 

with care‟. The label should also contain the name and address of the originating hospital 

and a direct contact in pharmacy in case of an emergency. 

Chemotherapy drugs must be delivered to a qualified nurse on the ward who takes 

responsibility for the appropriate storage, as defined on the label attached to the cytotoxic 

agent. 

Any cytotoxic drugs received by clinical areas, but not administered, must be safely 

returned to the Pharmacy Department as soon as possible. 

3.9 Storage in clinical areas 

Access to cytotoxic drug storage in clinical areas must be limited to authorised staff. 

Storage must be designed in a manner that will prevent containers of cytotoxic drugs 

from falling. Such storage areas should be clearly labelled with cytotoxic warning labels. 

A member of nursing staff must receive the cytotoxic drug dose in the transit box at its 

destination. Boxes will not be left unattended or with untrained staff on arrival. 

Nurses are responsible for the correct storage of cytotoxic drugs delivered to wards and 

clinics prior to use. The storage should be in appropriate and designated areas. 

Parenteral doses of chemotherapy should be stored in a designated locked 

chemotherapy refrigerator or cupboard separately from other drugs. 

Oral doses can be stored in a locked drug trolley, Patient Own Drugs (POD) locker, 

cupboard or refrigerator with other medication, as long as they are clearly labelled as 

cytotoxic. 

Any refrigerators used for the storage of chemotherapy doses should be monitored at 

least daily to ensure that the temperature is maintained between 2 to 8 degrees 

centigrade. 

3.10 Health and Safety 



For healthcare personnel the potential of exposure to cytotoxic agents exists during tasks 

such as drug reconstitution and preparation, administration and disposal of waste equipment 

or patient waste. Hence, all staff involved in the prescribing, preparation, delivery, 

administration of cytotoxic drugs as well as staff caring for patients receiving cytotoxic drugs 

must be aware of all health and safety procedures. This applies to clinicians, nursing staff, 

pharmacy staff, domestic staff in the relevant pharmacy and clinical areas, and portering staff 

carrying cytotoxic drugs or cytotoxic waste. 

The more common routes of exposure are contact with skin or mucous membranes (e.g. 

spillage and splashing), inhalation (over-pressurising vials), and ingestion (e.g. through 

eating, drinking or smoking in contaminated areas or from poor hygiene). Less likely routes 

of exposure include needle-stick injuries, which can occur during the preparation or 

administration of these drugs. 

Some cytotoxic drugs can cause acute or short term health effects including irritation to the 

skin, eyes and mucous membranes. 

All relevant new employees should receive an induction related to the current 

Chemotherapy Policy as soon as possible after commencement of employment. 

Records must be kept of all designated posts that require nursing, pharmacy or medical 

staff to reconstitute or administer cytotoxic drugs. The Health and Safety Executive 

recommends that the records should contain at least the following: surname, forename, 

gender, date of birth, permanent address and postcode, National Insurance Number, 

date when present employment started and a historical record of jobs in this employment 

involving exposure to cytotoxic drugs. 

Employees should notify their managers as soon as possible if they are pregnant, breast 

feeding or trying to conceive. This is particularly important as the greatest risk is during 

the first three months of pregnancy, when rapid cell division and differentiation occurs. 

At the point where an employee discloses pregnancy, a risk assessment specific to the 

individual should be carried out and any appropriate action taken. 

Pregnant or breastfeeding staff will be excluded from working with cytotoxic drugs. Staff 

will not be expected to be involved in directly preparing or administering cytotoxic agents 

or handling waste from patients treated with cytotoxic agents. If appropriate, the line 

manager and Human Resources Department, together with the member of staff, will 

agree any new temporary arrangements. 

New, expectant and breastfeeding mothers should be specifically advised against any 

direct involvement in the management of a cytotoxic drug spillage. 

A full COSHH (Control of Substances Hazardous to Health, 1998) assessment must be 

undertaken in all areas handling cytotoxic drugs. 

Pharmacy staff preparing cytotoxic drugs within pharmacy preparation units will wear 

personal protective clothes as defined by local standard operating procedures. 

The following protective equipment should be worn when administering cytotoxic drugs in 

clinical areas: 

Gloves NB Consideration needs to be given as to whether the procedure requires 

sterile or non-sterile protective gloves. 

Plastic apron. 



Eye protection: The use of eye protection should be considered whenever 

splashes or sprays of cytotoxic drugs might be generated, for example during 

intracavitary administration. 

Protective equipment for handling waste from patients receiving cytotoxic agents: 

Gloves 

Plastic apron. 

Protective equipment to be used in the event of a cytotoxic spillage: 

Gloves 

Protective disposable gown. 

Protective plastic armlets. 

A recommended brand of goggles. 

Plastic overshoes. 

Masks (preferably respirators). 

Cuts and scratches on the skin should be covered with a waterproof dressing to prevent 

infiltration of the skin if gloves are damaged. Staff with dermatological conditions (e.g. 

eczema) should be referred to occupational health for assessment. 

No glove material is completely impermeable to cytotoxic drugs. Permeation of cytotoxic 

drugs depends upon glove material, thickness and integrity, the properties of the 

drug/solvents and the contact time with the drug. Since no material is completely 

impermeable to cytotoxic drugs and permeability increases with time, users should 

minimise contact and change their gloves regularly. 

Gloves must be changed immediately if damaged or if any contamination occurs. 

Gloves should be changed regularly and must always be changed between patients. 

Non-powdered gloves must be used since powder may absorb cytotoxic contamination. 

If the inner surface of a glove becomes contaminated, exposure will occur. Therefore 

once disposable gloves are removed, they should not be re-applied, but disposed of as 

detailed in section 3.17. 

Hands must be washed thoroughly with liquid soap or alcohol gel applied before gloves 

are put on and after gloves are removed. 

Spillage kits and bottles of sterile saline for dealing with eye contamination must be 

readily available in all areas where handling of cytotoxic drugs occurs. 

Respiratory protection should be used when dealing with a cytotoxic spillage. 

3.11 Venous Access 

A venous access assessment must be conducted and documented prior to the 

commencement of any intravenous chemotherapy regimen. 

Intravenous Chemotherapy should NOT be given if there is any doubt regarding the 

safety of the venous access device. 

Small gauge polyurethane cannulae, which preserve vein integrity and cause least pain 

to the patient, are recommended. A closed system with Luer-lock attachments should be 



used. Peripheral cannulas should be changed every 72 hours irrespective of the 

presence of infection unless a clinical decision is made and recorded to leave the 

cannula insitu for longer for example in patients who have poor venous access. 

Central venous access is the route of choice if the drugs or fluids are to be administered 

over a long duration, are irritant to the peripheral veins, or have the potential to cause 

tissue necrosis. 

Where the recipient of therapy has insufficient or unsuitable peripheral veins, insertion of 

a central venous catheter may be indicated. 

Some therapies will justify the placement of non-tunnelled, percutaneous central venous 

catheters. However, several months of intensive therapy may indicate the need for longterm 

tunnelled catheters or implantable devices. 

The care of central venous catheters should follow Trust Policy. 

When choosing a suitable site, both the required cannula size and the size and condition 

of available veins must be taken into consideration. The following need to be considered: 

The purpose of the cannulation. For example a large vein required for high flow rate. 

Vesicant /Irritant solutions or drugs require good flow to assist haemodilution. 

The condition of the accessible vein, the lumen and blood flow. 

Small visible but impalpable superficial veins are rarely suitable for cannulation. 

In the elderly patient particularly, prominent, superficial veins may be sclerosed, 

tortuous, fibrosed or fragile and therefore unsuitable for cannulation. 

The superficial veins of the arm are commonly chosen for the cannulation as they are 

numerous, easily detectable with wide lumens and thick walls and the skin is less 

sensitive. Most common are: median cubital, basilic and cephalic veins. 

Veins in the lower limbs should be avoided in adults. 

Avoid use of dominant arm in order to maintain patient mobility and independence 

whenever possible. 

Avoid areas of joint flexion. 

Avoid use of cubital fossa, especially for vesicants. 

Avoid sites distal to recent cannulation or venopuncture to minimise the risk of fluid 

extravasation. 

Avoid areas proximal to skin lesions or wounds. 

Avoid veins close to arteries or deep lying vessels as accidental puncture can cause 

painful spasm or prolonged bleeding. 

Avoid areas affected by invading tumour, haematoma, inflamed or sclerosed areas. 

Avoid limbs where there is lymphatic impairment following surgery, chemical 

occlusion or radiotherapy even if there is no obvious lymphoedema. 

The venous access assessment should be reviewed if any problems are encountered 

during cannulation. 

If the patient is very nervous or needle phobic, local anaesthetic cream may be applied to 

the proposed site at least 30 minutes prior to the procedure. In severe circumstances 

sedation and / or relaxation techniques may be considered. The cream should be 

prescribed on the patient‟s drug chart. 

3.12 Administration 

The following section does not apply to patients admitted to non-oncology wards on oral anti 

cancer medication (please see section 3.16). 



Only nurses who have received appropriate training and have been assessed as 

competent, may administer intravenous chemotherapy drugs (Oncology and 

Haematology Directorate only). 

Nurses participating in a programme of training to become competent in the 

administration of chemotherapy may administer chemotherapy under the direct 

supervision of a chemotherapy competent practitioner(Oncology and Haematology 

Directorate and Child Health only). 

Systemic anti cancer therapy should only be given within Woolverstone Day Unit, 

Chemotherapy outreach clinics, Somersham Ward and Boxford Assessment Unit (in 

exceptional circumstances on Bergholt ward). 

Chemotherapy given to Teenage & Young Adults (18-24) should only be given on 

Somersham ward or in a designated cubicle within Woolverstone Day Unit. 

In exceptional circumstances, chemotherapy may be administered to cancer patients on 

the critical care unit by chemotherapy competent nurses. 

Registered nurses are responsible for safe administration of chemotherapy prescribed to 

the correct patient as outlined in the Trust‟s Medication Policy and the Nursing and 

Midwifery Council (NMC) Policy. 

Nursing staff who solely check chemotherapy will be required to complete modules 1-4 of 

the Anglia Cancer Network Chemotherapy Core Education Package. 

All prescriptions and accompanying treatment plans for chemotherapy must be checked 

by a chemotherapy competent nurse as outlined in section 4 (Oncology and 

Haematology Directorate only). 

The administering nurse is responsible for ensuring that: 

All relevant investigational parameters have been checked as outlined in 

individual chemotherapy protocols. 

The patient is fully informed of their treatment and has given consent 

The correct weight and height have been recorded where relevant. 

The body surface area calculations are correct. 

An accurate dose has been prescribed. A maximum of a 5% variance (according 

to protocol dosages) in dosage calculation is permitted. Discrepancies must be 

clarified with the doctor. 

Dose modifications to previous treatments are maintained if appropriate. 

All chemotherapy and supportive therapies including antiemetics have been 

prescribed. 

The route of administration and the duration of infusion have been specified on 

the prescription. 

There is an appropriate interval between treatments. 

Any history of toxicities and complications from previous cycles is documented in 

the patient‟s medical notes. 

Patients should be assessed for the need of any additional psychological, emotional, 

social or spiritual support, e.g. holistic assessment. An assessment of the carer‟s 

needs should also be offered. This assessment will be carried out by either the 



site specific nurse specialist or one of the chemotherapy nurses and will be 

documented. 

A nurse must not accept verbal orders for chemotherapy or for adjustments to doses of 

chemotherapy drugs. 

Double-checking of chemotherapy doses is required. A registered nurse, doctor or 

pharmacist (who has not been involved in the dispensing process) familiar with 

chemotherapy administration should perform the second check. 

All areas in which chemotherapy is administered must have the following equipment: 

Emergency call bell. 

Resuscitation equipment (or access to it as defined by local practice). 

Drugs for the management of emergencies – cardiac arrest and anaphylaxis. 

Extravasation kit. 

Cytotoxic spillage kit. 

Eye wash / access to running water. 

Prior to administering chemotherapy the health care professional to administer the drugs 

will: 

Check the patient/carer has been fully informed and has given consent to receive 

the proposed chemotherapy treatment. 

Check regimen and cycle number 

Check the number of administrations as per the schedule within the cycle 

Check the prescription is dated correctly, signed, written clearly and 

unambiguously and is in accordance with the chemotherapy protocol. 

Check body surface area and dose calculations, as necessary. 

Check pre-chemotherapy investigations, as outlined in the individual protocol, 

have been completed and results reviewed by an Oncology / Haematology doctor, 

designated chemotherapy competent nurse and an appropriate specialised 

pharmacist. 

Be aware of the side effects of all the drugs to be administered. 

Check cumulative doses have not been exceeded for anthracyclines / bleomycin. 

Check appropriate antiemetics have been prescribed and given. 

When the protocol contains premedications or hydration, ensure that these are 

prescribed and given in line with the protocol. 

Explain the procedure to the patient/carer and ensure written information has 

been provided. 

With a second person (as defined above), check the following details (if there is a 

discrepancy contact the Pharmacy Cytotoxic Preparation Unit or, out of hours, the on-call 

pharmacist): 

The patient‟s name and hospital number correspond with the prescription chart 

and pharmacy label. 

Chemotherapy must be administered on the date stated on the prescription. 

The name of the drug, the dose, route and for parenteral doses, the diluent, the 

prescription and pharmacy label must be identical. 

For parenteral doses the volume of fluid prescribed must correspond to the 

volume stated on the label OR the volume of fluid in a syringe must correspond to 

the volume stated on the label. 

Check the name on the patient's wristband corresponds to the prescription chart 

as per Trust Patient Identification (Wristband) Policy 



Check the route of administration is the same on the cytotoxic product label and 

the prescription. 

Check the expiry of all drug doses 

Check all parenteral doses for particulate contamination e.g. precipitation before 

administration. 

3.12.1 Administration of Intravenous Chemotherapy 

Equipment required: 

Relevant patient documentation, consent form and prescription sheet. 

Sterile dressing pack or sterile field and gauze. 

Chemotherapy drugs in sealed plastic bags. 

Deep, impermeable tray, disinfected with 70% Isopropyl alcohol.. 

Appropriate pump and giving set if required for infusional chemotherapy. 

A bag of a compatible infusion solution. 

Single use disposable wipe impregnated with 2% Chlorhexidine 70% Isopropyl 

alcohol for disinfection of hubs and ports 

Appropriate protective clothing. 

Cytotoxic sharps bin. 

Use of aseptic technique should be maintained throughout intravenous administration. 

The administering practitioner must ensure appropriate venous access with regards to: 

Site 

Position 

Patency 

Integrity 

Visibility 

Check the patency of the cannula or central line, by aspirating for blood and 

flushing with a compatible infusion fluid. 

If there are any doubts regarding cannula patency, recannulate the patient. 

If the placement or patency of central access is in doubt, imaging should be requested 

prior to commencing treatment. 

Inspect sealed bags before opening to ensure no spillage has occurred within the bag. 

Open the chemotherapy doses directly onto the disinfected tray. 

Patient details should be confirmed with their wristband, immediately prior to 

administration by the person giving the treatment. 

Thoroughly wash and dry hands or use alcohol hand gel prior to glove application. (Refer 

to Infection Control Policy). 

Ensure appropriate protective clothing is worn prior to handling syringes or infusion 

bags containing cytotoxic drugs. 

Disinfect injection ports with single use disposable disinfectant wipe impregnated with 

2% chlorhexidine 70% Isopropyl alcohol and allow to dry. 

Do not use the „Flip cap port‟ of the cannula, where present, for bolus administration. 



Administration should be performed over a towel with waterproof backing to protect skin 

and surfaces from potential cytotoxic drug leakage. 

A fast running infusion of a compatible infusion solution should be used for the 

administration of all intravenous bolus drugs. 

Maintain a closed system by using Luer-lock syringes. Use intravenous administration 

sets and syringes with Luer-lock fittings. 

To ensure visibility at all times, bandages must not be applied to cannula sites when 

intravenous chemotherapy is in progress. 

Administer the drugs in the correct order, vesicants should be administered first. Vinca 

Alkaloid miniags, if part of the regimen, should be administered first except if an 

anthracycline is to be administered in which case this should be administered before the 

vinca alkaloid minibag. 

The patient and the vascular access device should be monitored frequently before, 

during, and after administration for: 

Leakage at the site. 

Venous irritation. 

Phlebitis. 

Flare reaction. 

Allergic reaction. 

Anaphylaxis. 

Extravasation. 

Known side effects. 

Stop administration if: 

There is any doubt about the checks that have been carried out. 

The patient requests the treatment to stop. 

The patient demonstrates side effects or complications, particularly signs of 

anaphylaxis or extravasation. 

The equipment fails to function effectively. 

Check for blood return every 2-5 mls during bolus administration and before and after 

each drug during bolus administration. 

Do not expel air from syringes. If air is in a syringe, hold it in such a way that the air is up 

near the plunger when the entire drug is expelled and the air is reached. 

3.12.2 Intravenous infusional chemotherapy 

Infuse the first 20mls of the flushing solution and ask the patient to report any discomfort. 

Using a non-touch technique, carefully insert the giving set into the infusion at waist 

height to minimise the risk of personal contamination in the event of a spillage. This 

should be carried out over a clean tray. It is recommended that the bag is in a horizontal 

position and the port through which the set is placed is not kinked. This reduces the risk 

of the giving set piercing through the port and causing a leakage. 

Ensure that the infusion pump is set to the correct rate according to prescription and 

protocol. Ensure that the infusion solution is covered to protect it from light if the drug is 

prone to photodegradation. 



Advise patient to report adverse local and systemic symptoms. 

Commence infusion and ensure that the patient has easy access to a call bell and items 

for the management of potential emesis. 

Maintain regular observation of IV catheter sites for signs of swelling or inflammation, the 

patient for adverse signs and symptoms and the rate of infusion. VIP scores should be 

performed every 4 hours. 

Vinca alkaloid minibags should be administered first, unless an anthracycline is to be 

administered, via a gravity infusion over 5 to 10 minutes. 

The administering nurse should remain with the patient throughout the administration of 

vinca alkaloid minibags. 

If a special giving set or filter is required use only those recommended. Failure to use the 

correct infusion set and/or filter may risk personnel contamination, dose reduction and 

adverse clinical event for patient. 

On completion of dose administration clear away and dispose of all equipment, waste 

and sharps as outlined in section 3.17. 

Record the administration on the prescription sheet, in the medical and nursing notes. 

3.12.3 Subcutaneous chemotherapy 

Equipment required: 


Clean impermeable tray. 

26 gauge needles for administration. 

Cytotoxic waste bin. 

Ensure patient privacy. Ensure the patient is comfortable and has any specific 

information required. 

Inspect sealed bag before opening to ensure there is no spillage within the bag. Open 

the bag directly onto the injection tray. 

Explain the procedure to the patient. 

Thoroughly wash hands or use alcohol gel prior to glove application. (Refer to Infection 

Control Policy). 

Choose a suitable site for the injection. 

Carefully remove the connector top from the Luer-lock syringe and attach a 26-gauge 

needle with a needle length of 8mm. Ensure needles for administration are secure 

taking great care to minimise risk of spillage on the skin. 

Using a pinch technique, administer the injection using a 90 0 angle. Aspiration is not 

required prior to the injection. 

Remove the syringe and needle, covering the site with gauze and ensuring there is no 

leakage from the site. 



If further injections are required, rotate the site of administration. 

Dispose of all cytotoxic contaminated waste immediately as described in section 3.17. 

3.12.4 Intramuscular chemotherapy 

Equipment required 


Clean impermeable tray. 

24 or 22 gauge needles for administration. 

Skin cleanser- 2% Chlorhexidine 70% Isopropyl alcohol (Chloraprep).. 


Ensure patient privacy. Ensure patient is comfortable and has any specific information 

required. 

Inspect sealed bag before opening to ensure there is no spillage within the bag. Open 

the bag directly onto the injection tray. 

Explain the procedure to the patient. 

Thoroughly wash hands or use alcohol hand gel prior to glove application. (Refer to local 

Infection Control Policy). 

Choose a suitable site for the injection, and prepare the skin as per local policy. 

Carefully remove the connector top from the Luer-lock syringe, attach a green or orange 

needle. Ensure needles for administration are secure taking great care to minimise risk 

of spillage on the skin. 

Administer the intramuscular injection using the Z track technique. The Z-track technique 

involves displacing the skin and the subcutaneous layer in relation to the underlying 

muscle so that the needle track is sealed off before the needle is withdrawn, therefore 

minimising reflux. 

Remove the syringe and needle, covering the site with low lint gauze and ensuring there 

is no leakage from the site. 

If further injections are required, rotate the site of administration. 


3.12.5 Intravesical administration 

Mitomycin and occasionally epirubicin can be given by the intravesicular route. 

Careful consideration and discussion with the Urology nurse practitioner and Doctor 

responsible must occur if the patient has heavy haematuria or a urinary tract infection, or is 

immunosuppressed, due to the potential increase in side effects. 


1 pair of disposable latex / PVC gloves. 

1 pair of sterile gloves. 

Urinary drainage bag or catheter valve for in patient treatment. 

Disposable incontinence pads. 




Dressing trolley. 

Chemical safety glasses. 

Dressing pack. 

Clamps. 

Luer lock adaptor 

Procedure with a catheter in situ 

Thoroughly wash hands. (Refer to local Infection Control Policy). 

Clean dressing trolley with locally approved cleaning solution. 

If required, catheter insertion and management of existing catheters should follow local 

policy and principles of best practise. 

Ensure that consent has been obtained. 



Advise the patient to report any adverse local and systemic symptoms. 

Provide the patient with a gown and assist patient to assume a recumbent or semirecumbent 

position and expose the catheter. 

Lay an incontinence pad under the catheter and over the thighs. 

Thoroughly wash hands prior to glove application. (Refer to local Infection Control 

Policy). 

Open and assemble the sterile products and don one pair of sterile gloves. 

If an irrigation bag is in use, disconnect the fluid and spigot the catheter inlet. 

Clamp the catheter. 

If necessary, disconnect the drainage bag from the catheter. Document the volume of 

urine to ensure an accurate fluid balance is recorded. Put the catheter valve in a closed 

position to provide a means of blocking the catheter and to facilitate drainage after the 

recommended time. 

Connect the syringe securely to the catheter via the luer lock adapter release the clamp 

and instill the drug slowly into the bladder. Rapid instillation can be painful, especially if 

the bladder wall is scarred from previous surgery. 

Carefully check that there are no signs of leakage of drug around the catheter site. 

Clamp the catheter. Disconnect the syringe from the valve using a cotton swab to 

absorb any drops left on the end of the valve. 

If a drainage bag is being used, connect this to the valve but do not open the valve, to 

allow retention of the drug within the bladder for at least one hour. 

Clear away all contaminated disposables. (See section 3.17). 

Ensure the comfort of the patient, assisting him/her to reposition themselves and ensure 

they have easy access to a call bell. 

Advise the patient of the need to retain the drug for one hour if possible. If the patient 

has an urge to void or if the catheter is bypassing, it will be necessary to open the valve 

before the allotted time. 

After one hour: Wash hands thoroughly before putting on disposable gloves. 

Attach a urine drainage bag. Unclamp the catheter and allow drainage of the bladder 

contents into the drainage bag for 15 minutes. 

Remove the drainage bag and connect a new one if the catheter is to remain in situ, as 

per local policy. 

If the catheter is to be removed attach a syringe to the balloon inlet of catheter. Once 

correct balloon inflation volume has been removed with syringe, gently remove the 

catheter completely, ensuring disposable sheet under meatus of urethra. 

The contents of the drainage bag (drug and urine) should be emptied into a sluice 

followed by two flushes. The bag should then be disposed of as cytotoxic waste. 




Procedure without a catheter in situ 

Thoroughly wash hands. (Refer to local Infection Control Policy). 

Clean dressing trolley with locally approved cleaning solution. 

Ensure that consent has been obtained. 




If necessary, provide the patient with a gown and assist patient to assume a recumbent 

or semi-recumbent position. 

Catheterise the patient (as per guidelines) using disposable self lubricated single use 

catheter size 10Ch. . 

Thoroughly wash hands prior to glove application. (Refer to local Infection Control 

Policy). 

Open and assemble the sterile products and don one pair of sterile gloves. 

Connect the bladder syringe securely to the catheter, open the valve and instill the drug 

slowly into the bladder. Rapid instillation can be painful, especially if the bladder wall is 

scarred from previous surgery. 

Remove the catheter (and attached syringe). 

Clear away and dispose of all cytotoxic contaminated waste immediately as described in 

section 3.17. 

Advise the patient of the need to retain the drug for one hour. 

After one hour: Advise the patient to go to the bathroom to void urine into toilet. Men 

must void sitting down to minimise splashing. The toilet should be flushed , with the lid 

down (again to minimise splashing). 

If patient unable to void insert self lubricated single use catheter (as before) and drain 

the bladder. 

Advise patients to wash genitalia thoroughly with plenty of soap and water and wash 

their hands afterwards, to minimise potential skin problems following contact with 

cytotoxic drugs. 

Advise patient to maintain hygiene as normal after the initial emptying of their bladder. 

If any cytotoxic drug comes in contact with the patients skin, refer to section 3.18. 

3.12.6 Intrapleural administration 

Following drainage of a pleural effusion, the doctor may wish to instil a cytotoxic drug, usually 

bleomycin, into the pleural cavity, via the mechanism used for drainage, i.e. the pleural drain. 


Dressing trolley and dressing pack. 

10 ml Sodium Chloride 0.9%. 

10 ml syringe and needles, as required. 

Sterile gloves and plastic apron. 


Incontinence sheet (x 2). 

Hypoallergenic tape. 

Procedure 

Thoroughly wash hands before preparing required equipment. 



Advise the patient to report adverse local and systemic symptoms. 

Position the patient sitting up, as for drainage of pleural effusion. 

Take equipment trolley to the bedside. 



Place an incontinence sheet under the patient and another over clothing on the side of 

the aspiration/instillation. 

Thoroughly wash and dry hands prior to glove application. (Refer to local Infection 


Ensure protective eyewear is worn. 

Open and assemble sterile products and one pair of sterile gloves. 

Nursing staff should assist with the administration procedure as required. 

Pre-medication should be administered prior to the pleurodesis procedure, as 

prescribed. 

The cytotoxic drug should be instilled into the pleural cavity by an appropriately trained 

and accredited doctor. 

The intercostals tube should be clamped for one hour following intrapleural 

administration of the cytotoxic drug. This prevents the drug from immediately draining 

back out of the pleural space. 

Patient rotation is not necessary after intrapleural administration, except for when talc is 

used (reference 14). 

Following administration by the doctor, ensure the patient has easy access to a call bell 

and items for the management of potential emesis. 

Dispose of all cytotoxic contaminated waste immediately into cytotoxic waste bin. 

Wash hands thoroughly after the procedure. 

Drain fluid if required and dispose of as “Cytotoxic Waste” (see section 3.17). 

3.12.7 Intraperitoneal administration 

Following drainage of the peritoneum, the doctor may wish to instil a cytotoxic drug(s) into 

the peritoneal cavity, via the mechanism used for drainage. 


Dressing trolley and dressing pack. 

10 ml Sodium Chloride 0.9%. 

10 ml syringe and needles, as required. 

Sterile gloves and plastic apron. 


Incontinence sheet (x 2). 

Hypoallergenic tape. 

Procedure 

Wash hands before preparing the required equipment 




Position the patient supine with one or two pillows and with the peritoneal access site 

exposed. 

Take equipment trolley to the bedside. 

Place an incontinence sheet under the patient and another over clothing on the side of 

the aspiration/instillation. 

Thoroughly wash and dry hands prior to glove application. (Refer to local Infection 


Ensure protective eyewear is worn. 

Open and assemble sterile products and one pair of sterile gloves. 

The cytotoxic drug should be instilled into the peritoneal cavity by an appropriately 

trained and accredited doctor. 

Nursing staff should assist with the administration procedure as required. 



Following administration by the doctor, ensure patient has easy access to call bell and 

items for the management of potential emesis. 

Dispose of all cytotoxic contaminated waste immediately into cytotoxic waste bin. 

Wash hands thoroughly after the procedure. 

To ensure the drug comes into contact with the entire peritoneal cavity, turn the patient 

as follows 

Lay on left side. 

Lay on the back. 

Lay on the right side. 

Lay on the front. 

The duration in each position should be 15 minutes, unless otherwise prescribed. Wash 

hands thoroughly after the procedure. 

Drain fluid if required and dispose of as “Cytotoxic Waste” (see section 3.17). 

3.13 Extravasation 

Extravasation refers to the accidental infiltration of a drug that has been administered via the 

intravascular route into surrounding subcutaneous tissues. It can be associated with 

extensive tissue damage. 

Speed of diagnosis and prompt initiation of treatment is imperative in the effective 

management of extravasation of cytotoxic agents. 

Treatment will be dependant on the classification of the cytotoxic drug. 

All assessment and treatment interventions must be prescribed by a Consultant, 

Specialist Registrar, Staff grade or Clinical Assistant. 

The patient‟s consultant must review any extravasation of cytotoxic drugs. 

Extravasation of a vesicant drug should be treated as a medical emergency and 

treatment should ideally be initiated within 1 hour of the incident. 

A referral to a plastic surgeon should be considered for extravasations of vesicant 

drugs and patients referred promptly if felt necessary. 

If clinical judgement dictates alternative treatment to that described in this protocol full 

details of the rationale and the intervention should be documented in the patient‟s 

notes. 

3.13.1 Diagnosis 

Extravasation should be suspected if one or more of the following symptoms occur: 

Increased resistance when administering IV drugs 

Lack of blood returned from the cannula/CVAD 

Change in infusion quality, i.e. reduce flow rate 

Any change in colour such as redness/blanching at the injection site 

Swelling or oedema around the cannula 

Pain or discomfort around the cannula site (stinging or burning) 

Inflammation, erythema or blistering around the infusion site 

Note: The above points are not diagnostic but in combination they MAY indicate 

extravasation. 



The degree of damage caused by extravasation relates to the type and amount 

of drug extravasated and the speed with which it is recognised and treated. 

Delays in recognition and treatment can increase the risk of tissue necrosis. 

3.13.2 Classification of cytotoxic drug 

Drugs are classified in this protocol according to whether they are irritant, exfoliant, nonvesicant 

or vesicant. Treatment of vesicant extravasation is further classified as 

anthracycline or non-anthracycline. 

Vesicant: capable of causing pain, inflammation and blistering of the skin, underlying 

flesh and necrosis, leading to tissue death and necrosis. 

Exfoliant: capable of causing inflammation and shedding of the skin but less likely to 

cause tissue death. 

Irritants: capable of causing inflammation and irritation, rarely proceeding to breakdown 

of tissue. 

Drug Classification Treatment 

Aclarubicin 

Irritant/Exfoliant/Non Cold compress 

Vesicant 

Actinomycin D 

(Dactinomycin) 

Vesicant 

Hyaluronidase and saline flush 

out 

Alemtuzumab 


Vesicant 

Amsacrine Vesicant Hyaluronidase and saline flush 

out 

Arsenic 


Vesicant 

Aspariginase 


Vesicant 

Azacytidine 


Vesicant 

Bevacizumab 


Vesicant 

Bleomycin 


Vesicant 

Bortezomib 


Vesicant 

Busulfan Vesicant Hyaluronidase and saline flush 

out 

Carboplatin 


Vesicant 

Carmustine Vesicant Hyaluronidase and saline flush 

out 

Cisplatin 

Cladribine 

Irritant/Exfoliant/Non 

Vesicant 


Vesicant 

Cold compress 

Cold compress 



Clofarabine 


Vesicant 

Cyclophosphamide 


Vesicant 

Cytarabine 


Vesicant 

Cetuximab 


Vesicant 

Dacarbazine Vesicant Hyaluronidase and saline flush 

out 

Dactinomycin 

(Actinomycin D) 

Vesicant 

Hyaluronidase and saline flush 

out 

Daunorubicin Vesicant anthracycline Hyaluronidase and saline flush 

out 

+ dexrazoxane 

Docetaxel 


Vesicant 

Doxorubicin Vesicant anthracycline Hyaluronidase and saline flush 

out 

+ dexrazoxane 

Epirubicin Vesicant anthracycline Hyaluronidase and saline flush 

out 

+ dexrazoxane 

Etoposide 


Vesicant 

Floxuridine 


Vesicant 

Fludarabine 


Vesicant 

Fluorouracil 


Vesicant 

Gemcitabine 


Vesicant 

Gemtuzumab 


Ozogamicin 

(Mylotarg) 

Vesicant 

Idarubicin Vesicant anthracycline Hyaluronidase and saline flush 

out 

+ dexrazoxane 

Ifosfamide 


Vesicant 

Interleukin – 2 


Vesicant 

Irinotecan 


Vesicant 

Liposomal 


Daunorubicin 

Liposomal 

Doxorubicin 

(Adriamycin) 

Melphalan 

Methotrexate 

Vesicant 


Vesicant 


Vesicant 


Vesicant 

Cold compress 

Cold compress 

Cold compress 



Mitomycin C Vesicant Hyaluronidase and saline flush 

out 

Mitoxantrone 


Vesicant 

Mylotarg 


(Gemtuzumab 

Ozogamicin) 

Vesicant 

Oxaliplatin 


Vesicant 

Paclitaxel 


Vesicant 

Panitumumab 


Vesicant 

Pegasparaginase 


Vesicant 

Pemetrexed 


Vesicant 

Raltitrexed 


Vesicant 

Rituximab 


Vesicant 

Streptozocin Vesicant Hyaluronidase and saline flush 

out 

Teniposide 


Vesicant 

Thiotepa 


Vesicant 

Topotecan 


Vesicant 

Trastuzumab 


Vesicant 

Treosulfan Vesicant Hyaluronidase and saline flush 

out 

Vinblastine Vesicant Hyaluronidase and saline flush 

out 

Vincristine Vesicant Hyaluronidase and saline flush 

out 

Vindesine Vesicant Hyaluronidase and saline flush 

out 

Vinorelbine Vesicant Hyaluronidase and saline flush 

out 



3.13.3 Intervention and Treatment 

Use the above table to assess classification of drug and treat according to classification of 

drug and type of venous access. 

Extravasation Suspected 

Peripheral line 

Stop infusion/injection immediately 

DO NOT REMOVE CANNULA 

Disconnect Infusion 

Aspirate as much of the drug as possible 

from the cannula with a 10ml syringe 

Collect the extravasation kit & inform Dr 

immediately of irritant/vesicant suspected 

extravasation 

Central Venous Access Device 

Stop infusion/injection immediately & disconnect 

Aspirate drug from line 

Collect extravasation kit and inform Dr 

immediately of suspected irritant/vesicant 

extravasation 

Central line to remain in-situ 

Mark around area with a pen 

Remove cannula and mark around the area 

with a pen 

Elevate Limb 

Dr to prescribe treatment according to classification of drug and inform responsible 

consultant (out of hours consultant on-call) 

Irritant/ Exfoliant/ Non-Vesicants 

Apply cold compress to affected area for 20 

minutes, 4 times daily for 24 – 48 hours 

Vesicants (including vesicant 

anthracyclines) 

Dr to undertake “Hyaluronidase and saline flush out” 

procedure under local anesthetic if required. (see 

section3.13.4) 

If drug is a vesicant anthracycline, Consultant 

Oncologist / Haematologist to prescribe Dexrazoxane 

on prescription chart if indicated (see section 3.13.5). 

Peripheral line 

CVAD 

Consultant to consider referral to Plastic 

Surgeon for advice on further 

management and consideration of 

liposuction. 

Consultant to refer patient to Plastic 

Surgeon urgently for advice on further 

management 

Complete documentation 

• Datix form 

• National Extravasation Reporting Scheme Green Card / Extravasation form 

• Medical & nursing Documentation 



3.13.4 Hyaluronidase and saline flush out technique 

This should only be undertaken by an SpR or Consultant. 

Hyaluronidase is most effective if administered within 2 hours of the injury occurring, but 

still has benefits up to 12 hours. 

Under aseptic conditions clean the site of injury and the immediate surrounding area. 

Reconstitute one or two 1500 unit vials of Hyaluronidase in 5-10mls of Lidocaine 1%. 

Infiltrate the subcutaneous layer of the area immediately under the site of extravasation. 

Using a scalpel make at least 4 small “incisions” into the subcutaneous layerevenly 

spaced around the area to be treated. 

Insert the tip of a size 18/20g cannula, or 18g “drawing up needle” (which is blunt), 

through one of the 4 incisions. 

Using a syringe attached to a three-way tap flush up to 1000ml, in 10-20ml aliquots, of 

0.9% sodium chloride in turn through each of the 4 incisions. 

If the area surrounding the extravasations becomes oedematous gently massage the 

area towards the nearest incision site to allow excess fluid to be removed. 

Once the procedure has been completed, dress the area with a layer of jelonet and 

gauze and elevate the limb for 24 hours. 

Consider prescription of prophylactic antibiotics. 

The stab incisions should be allowed to close spontaneously and never be sutured. 

3.13.5 Vesicant anthracycline extravasation and dexrazoxane 

Vesicant anthracyclines are associated with considerable morbidity when involved in 

extravasation incidents. 

In the event of vesicant anthracycline extravasation, the plastic surgeons should be 

consulted and they should be specifically informed that the extravasation involves a 

vesicant anthracycline. Hyaluronidase and saline flush out technique should be 

performed as per section 3.13.4. If the flush out involves no significant delay it should be 

carried out prior to the dexrazoxane, otherwise commence the dexrazoxane without 

delay. 

Ideally, the plastic surgeon will make a baseline assessment. 

However, the administration of dexrazoxane should not be delayed while waiting for their 

advice. 

Dexrazoxane must be prescribed by a Consultant Oncologist or Haematologist or by the 

Plastic Surgeons. 

Dexrazoxane is recommended for the following indications: 

Anthracycline volume >5ml where extravasation is certain 

Anthracycline volume >10ml if extravasation is unclear 



Extravasation from central or PICC line. 

Dexrazoxane is administered into the unaffected arm daily for 3 days so appointments 

should be made for days 2 and 3 for administration of dexrazoxane and for assessment 

by plastic surgery. 

Following the 3 day administration of dexrazoxane, the plastic surgery team will advise 

on further management. 

3.13.6 Plastic surgeon review 

If the extravasation occurs via a peripheral line plastic surgeon referral should be considered. 

The patient should be referred for an urgent review by the plastic 

surgeon if: 

Drug is a vesicant or vesicant anthracycline 

Drug extravasated via a CVAD 

The skin is compromised 

Extreme swelling 

Significant extravasation 

Skin necrosis 

3.13.7 Follow up care 

The patient should be made aware that the site will remain sore for several days. 

Extravasation sites should be observed for pain, erythema, induration and necrosis and the 

findings recorded in the medical/nursing documentation. 

If the extravasation was caused by a vesicant drug appropriate arrangements should be 

made for follow up by the oncologist/haematologist or plastic surgeon. 

If the extravasation was caused by a non-vesicant drug the patient should be asked to report 

immediately any increase discomfort or significant change, i.e., peeling or blistering of the 

skin, to the Department. 

3.13.8 Documentation 

The signs, symptoms, date and time of the injury should be recorded on a National 

Extravasation Reporting Scheme Green Card / Extravasation form. This should then be 

photocopied and filed in the patient‟s medical notes as a permanent record of the 

assessment of the injury. 

The follow up report for the National Extravasation Reporting Scheme should be completed 

within 1 month following the incident. 

The following information should be documented in the medical records 

Time of review by medical staff 

Referrals made (who & time) 

Arrangements for subsequent follow up appointments required 

Outcome of follow up assessments 

A datix form should be completed. 



3.14 Out-of-hours initiation and administration of chemotherapy 

Whenever possible, all cancer chemotherapy should be initiated, and as much as is 

feasible, administered within normal working hours. The risk of accidents is increased 

when complex cytotoxic regimens are given outside normal working hours, particularly 

errors of incorrect drug and patient identification, and using the incorrect route of 

administration of cytotoxic drugs. 

Patients may only be commenced on a new chemotherapy regimen beyond normal 

Monday to Friday (09.00 to 17.30) working hours in the following circumstances: 

Acute Leukaemia - unanticipated admission of a newly diagnosed patient or a 

newly diagnosed relapsed patient. 

Haematological malignancy patient with CNS involvement. 

Superior vena cava (SVC) obstruction - in a patient with small cell lung cancer, 

germ cell tumour or a haematological malignancy. 

Spinal cord compression – in a patient with germ cell tumours, Ewing‟s sarcoma, 

neuroblastoma or a haematological malignancy. 

In exceptional circumstances, acute medical crisis brought on by rapidly growing 

tumour. 

A Consultant Oncologist or Haematologist must determine that it would be absolutely 

inappropriate to delay chemotherapy. The decision must be recorded in the medical 

notes by the responsible Consultant. 

Out of hours oral chemotherapy must only be prescribed by a Consultant or Senior 

Registrar who should consult the current UKALL protocol (located in the Paediatric 

Oncology nurses office). Patient‟s most recent blood results and drug percentages 

documented in the patient‟s notes as well as drug dosage on the front sheet of the 

patient‟s blue treatment folder ((located in the Paediatric Oncology nurses office). 

Pharmacy and relevant nursing staff should be contacted as soon as possible after the 

decision to treat a patient with chemotherapy out of hours has been made. 

3.15 Ambulatory and home chemotherapy treatment 

Chemotherapy is usually given in an appropriate hospital based facility. However, current 

practice of chemotherapy and cancer management means that many patients now receive 

chemotherapy in settings outside of conventional hospital facilities. 

The hospital-based team, regardless of the place of chemotherapy drug delivery retains 

the overall responsibility for the patient. It is essential however that the patients GP is 

informed of the method and place of chemotherapy delivery and the support package 

available, including 24 hour contact numbers. 

Many patients may be treated with regimens in which most of the chemotherapy doses 

are administered within the hospital setting, but may involve some part of their treatment 

also being managed or delivered at home or in the community setting. 

Such patients should be regularly reviewed by the hospital based medical or nursing 

team to ensure that they are still fit for treatment. The frequency of review will be 

dependant on local practice and the chemotherapy regimen. 



Patients must be provided with all appropriate supplementary equipment. This may 

include gloves, aprons, cytotoxic sharps bins, cytotoxic spillage kits and dressing packs. 

It is essential that patients and carers have received full information and advice 

concerning their chemotherapy treatment. They should also have been given adequate 

training and support regarding safe handling, storage and disposal of the drug doses and 

management of spillages and suspected extravasation. All patients are given emergency 

24 hour telephone numbers. 

The hospital based nursing or medical staff will undertake an assessment of patient 

suitability for continuous infusional chemotherapy before a patient is allocated to receive 

treatment. 

Walkmed pumps are available for patients receiving infusional chemotherapy. 

Only appropriately trained nurses/pharmacists will be allowed to program the device. 

Re-programming should take place after each completed patient episode. 

Patients based at the Ipswich Hospital requiring a mechanical device to infuse 

chemotherapy over a period of days would be connected to the infusion at Ipswich 

Hospital Oncology and Haematology department or an outreach clinic; by an 

appropriately trained nurse ; and then arrangements would be made for the patient to 

return to the department for disconnection of the infusion. At no point would the 

community staff or patient be expected to take on this role. 

The administration of subcutaneous cytotoxic boluses in this setting may be by the 

patient, the carer or an appropriately trained community nurse. The hospital based 

nursing or medical staff will undertake an assessment of patient suitability for treatment in 

the home or community setting. 

The patients understanding of the above will be assessed using a teaching checklist. 

Additional supplementary written information will also be provided. 

An home delivery services set up should be in accordance with the Trust Home Delivery of 

Medicines Policy. 

3.16 Oral chemotherapy preparations 

3.16.1 Principles 

Oral anti-cancer medicines are increasingly being used in hospitals and in the 

community. Risks are increased if non-specialist practitioners prescribe, dispense or 

administer these oral medicines and bypass the normal safeguards used for injectable 

anti-cancer medicines (NPSA/2008/RRR001). 

The prescribing and dispensing of oral chemotherapy should be carried out and 

monitored to the same standards as those for injectable anti- cancer therapy. 

All oral anti-cancer medicines must be prescribed in the context of a written protocol and 

treatment plan using an approved proforma and a copy filed in the Medical notes. 

Prescriptions for oral chemotherapy drugs must state clearly for each course of treatment 

the dose, frequency of administration, intended start date, duration of treatment and 

where relevant the intended stop date. 

For drugs for which a variety of schedules are common (e.g. capecitabine), it is essential 

that the intended schedule is unambiguously specified on every prescription. 



All intended deviations from protocol such as dose modifications should be clearly 

identified as such. 

Responsibility for the administration of oral drugs ultimately lies with the patient or their 

carer, but it is the responsibility of all members of the multi-disciplinary team to ensure as 

far as practically possible that they are adequately prepared for this. 

Effective communication between primary and secondary care, and with patients, is 

pivotal to safe and effective treatment. The prescribing and dispensing should remain the 

sole responsibility of the hospital-based oncologist or haematologist and pharmacist 

respectively. 

Before every treatment cycle, all patients should be seen by an oncologist, 

haematologist, specialist pharmacist or nurse. 

As most oral chemotherapy will be taken by patients in their home, it is essential that 

patients are adequately counselled about their drug therapy, the storage conditions and 

handling precautions. 

Patients should be advised that medicine spoons, oral syringes or cups should be 

reserved for cytotoxic treatment only, and not used for the administration of other drug 

doses. They should be washed thoroughly between doses, and safely disposed of after 

the treatment course. 

The oncologist, haematologist, specialist pharmacist or nurse must ensure that the 

patient or carer understand: 

How and when to take their medicines, including treatment „gaps‟ 

What to do in the event of missing one or two doses 

What to do in the event of vomiting after a dose 

Likely adverse effects and what to do about them 

The need for, and how to obtain, further supplies 

The role their GP is expected to play in their treatment 

Principles of safe handling, storage and disposal (see appendix I) 

The use of medicine spoons, oral syringes or cups 

As much of this information as possible should first be given at the pre-treatment visit and 

reinforced on subsequent visits. 

Patients should be provided with details of appropriate and readily accessible 24-hour 

points of contact, if further advice is needed. 

All Prescriptions must be screened by an appropriately trained and accredited pharmacist 

before dispensing. 

All pharmacy staff who are, or could be, involved with dispensing oral anticancer drugs 

must have access to full copies of the relevant protocols. The information available to the 

dispensary staff must address the management of toxicity, the criteria for midcourse dose 

adjustments or stopping treatment, and identify in what circumstances and with which 

drugs continuous rather than intermittent treatment may be used. 

All dispensary staff must have ready access to specialist oncology/haematology 

pharmacy advice. 



Dispensary staff should work to detailed standard operating procedures. 

Wherever possible pharmacy will purchase only blister or foil packed tablets or capsules 

of oral cytotoxic drugs. This will help ensure that accidental contamination is minimised. 

All oral chemotherapy drugs dispensed for all prescriptions, including inpatients, should 

be labelled as a TTA. The drug name, strength of the preparation, patient‟s name, 

quantity provided, full directions and an indication of length of treatment should be on the 

label as per local procedure. If the duration of treatment is not clear on the prescription, 

the prescriber should be contacted to clarify this. If the treatment is intended for a short 

defined course the labels should state this. For example, „Take THREE capsules ONCE 

a day for FIVE days, then STOP‟. 

All containers of oral cytotoxic preparations, for inpatients and outpatients, should be 

labelled with a „Cytotoxic‟ warning label. 

When dispensing within pharmacy, tablets or capsules should not be handled directly. All 

staff should use a „no touch‟ technique or wear gloves, to minimise the risks of exposure. 

Designated counting triangles, which are only used for cytotoxic drugs should be used. 

These should be cleaned after use with IMS (Industrial Methylated Spirit 70%), or an 

alternative locally approved agent, and a wipe. Wipes should be disposed of in a 

Cytotoxic Sharps bin after use. 

Oral cytotoxic tablets or capsules should not be dispensed in multi-compartment 

compliance aids or monitored dose systems without advice from a specialist Oncology 

pharmacist. 

When dispensing tablets or capsules, the complete course of treatment should be 

supplied. 

When dispensing short distinct courses of cytotoxic drugs in liquid formulations, the exact 

quantity required (plus an overage of approximately 10mls) should be supplied. Work 

over a leak-proof tray to contain any solution in the event of a spillage. For patients who 

are on maintenance treatment, it is more appropriate to dispense the drug in its original 

container. 

All patients must be given patient information leaflets. 

Oral cytotoxic preparations can be potentially hazardous if handled carelessly. 

Every step should be taken to ensure that accidental exposure, which may arise from 

handling uncoated tablets, loose capsules or oral liquids, is minimised. 

Oral formulations of cytotoxic drugs should not be handled directly. All staff should use a 

„no touch‟ technique or wear gloves, to minimise the risks of exposure. 

After handling any oral cytotoxic preparation, hands should be washed thoroughly. 

Tablets should never be crushed or halved and capsules should never be opened. 

Advice should be sought from pharmacy if alternative formulations are not available and 

this is thought to be essential. If an oral liquid formulation is not commercially available, 

the Pharmacy Department may be able to prepare an alternative liquid form. In such 



cases, doses will be extemporaneously prepared in an appropriate controlled 

environment to give a suitable form ready for administration to the patient. 

Patients should swallow tablets or capsules whole and not chew. Patients and carers 

should be advised to wash their hands thoroughly after taking or administering any 

cytotoxic medication. 

Do not use any tablets or capsules if loose powder or liquid is present in the container. 

Inform the Pharmacy Department and request replacements. 

Oral doses should be dispensed into a medicine pot/cup, prior to administration to a 

patient. If the tablet or capsule comes in a blister or foil packed presentation, the dose 

units should NOT be pushed out of the original packing. Instead, cut the required 

number of dose units from the dispensed strip and put in a medicine pot. The dose can 

then be pushed through the blister/foil wrapping by the patient or nurse at the bedside. 

This reduces the number of manipulations with the capsules or tablets, and prevents 

exposure from opened blisters kept in original containers. 

If a tablet or capsule is dropped, pick it up wearing gloves and put the dose in a plastic 

bag and dispose of it into a Cytotoxic Sharps box. Damp dust the area with a wet paper 

towel to ensure all fragments/particles are collected, and dispose of the towel as 

contaminated waste. 

If an oral liquid formulation is spilt, wearing gloves, soak up the spill and then clean the 

area immediately using soapy water and wipes or paper towels. Dispose of these into a 

Cytotoxic Sharps box. For large volumes (e.g. volumes greater than 50mls) consider the 

use of the cytotoxic spillage kit. 

After administration of oral cytotoxic drugs in hospital, spoons, medicine pots and oral 

syringes should be disposed of in a cytotoxic sharps bin. 

3.16.2 Prescribing and administration of oral cytotoxic medication in non-oncology 

areas 

Patients admitted to non-oncology wards on oral anti-cancer medication are at risk from 

uncontrolled prescribing. The Doctor must assess the patient‟s current medical condition 

to ensure suitability for continued treatment with the medicine and a detailed medication 

history must be taken to ensure all information on the dosage of the oral anti-cancer 

medicine is known. This also applies to oral anti-cancer medication for non-cancer 

indications (such as methotrexate for rheumatoid arthritis). A copy of the original 

prescription for the oral anti-cancer medication must be checked and the original 

prescriber informed of the admission. Where possible use the patient‟s own supply as the 

whole course will have been dispensed. 

Oral chemotherapy doses must be CLEARLY prescribed on the drug chart stating the 

dose, route and frequency of administration. This is especially important for weekly 

doses of chemotherapy medication, namely methotrexate, where crosses should be 

marked on the chart grid to avoid daily dosing. 

The duration of chemotherapy medication should also be marked on the drug chart for 

short(er) courses to avoid unnecessary dangerous continuation. 

The prescription must be clinically validated by a pharmacist at ward level before the drug 

can be dispensed and/or administered. To show this validation has occurred the chart 



will be endorsed by the pharmacist with „confirmed‟, „pharmacist‟ and their initials and 

date. A nurse/midwife must not administer an oral cytotoxic medication without this 

validation. This validation will also involve the checking of a patients own supply of 

medication when available to ensure it is safe and appropriate to administer. The oral 

cytotoxic drug will be marked with a purple sticker by pharmacy to indicate extra cautions 

are required. 

A nurse/midwife must also check with the patient that their chemotherapy medication is 

due before administration. 

A list of cytotoxic medication can be found as a laminated version in the drug trolley and 

on the Medicines Management intranet site. 

3.17 Disposal of cytotoxic waste 

3.17.1 Part used doses 

Place the syringe/bag in a yellow bag and place into a cytotoxic sharps box. These 

should be labelled as cytotoxic waste and sent for incineration. 

It should be clearly documented how much of the dose was administered and the 

reasons for discontinuation of treatment. Medical staff and pharmacy should also be 

notified. 

Unused Oral Doses. Any unused oral doses (e.g. tablets that have been dropped or oral 

liquids that have been refused etc) should be disposed of in a cytotoxic sharps box. To 

minimise the risk of damage and potential contamination, they should be discarded as 

follows: 

o Loose tablets/capsules: Put into a sealable plastic bag or a medicine bottle / 

sample pot securing the lid, before placing in a cytotoxic sharps box. 

o 

Oral liquids: Pour into a sample pot securing the lid, before placing in a cytotoxic 

sharps box. 

3.17.2 Used disposal equipment 

While wearing gloves and plastic apron place any needles, syringes, giving sets, empty 

ampoules/vials, infusion bags or packaging into a rigid cytotoxic sharps disposal box. 

Giving sets should not be removed from infusion bags prior to disposal. 

The sharps disposal box should be clearly labelled as cytotoxic waste so it can be 

incinerated at 1000ºC to ensure degradation of the cytotoxic agent. 

Sharps disposal boxes containing cytotoxic waste must be regularly collected. 

Re-usable plastic or metal trays should be rinsed with cold water (to remove traces of 

cytotoxic agents) and then washed with detergent and hot water (to prevent crosscontamination). 

Wear gloves. 

Reusable equipment (eyewear and respirators) may be cleaned thoroughly with mild 

detergent and water for reuse. 



Protective clothing, plastic aprons and gloves worn during the administration of 

chemotherapy should be placed in a clinical waste disposal bag or sharps box, marked 

as cytotoxic waste and sent for incineration. 

3.17.3 Patient Waste 

Patient waste e.g. urine, faeces, vomit may contain high concentrations of cytotoxic drugs 

or active metabolites both during administration and up to seven days after treatment has 

ceased. Particular care should be taken with patients receiving high dose chemotherapy 

or intravesical treatment. 

It has been shown that these unchanged cytotoxic drugs or active metabolites can be 

irritant to the skin, eyes and mucous membranes. Although evidence of long-term toxicity 

is inconclusive and conflicting, all staff handling waste should take reasonable 

precautions to limit exposure and ensure absorption does not occur. 

The use of universal precautions applies here as with all body fluids 

Wear gloves and protective aprons. 

Double flushing of sluices after emptying potentially cytotoxic contaminated 

matter from bedpans, catheter bags, dialysis bags etc is recommended. 

Staff are advised to follow the precautions described in the Control of Infection 

Policy. 

Soiled bedding and linen should be placed in a red soluble –seamed bag, closed and 

then placed into a red material bag and a cytotoxic hazard label attached. . 

3.18 Personal accidents and spillages 

3.18.1 Skin contamination 

If a patient, member of staff or visitor is involved in a spillage of cytotoxic drugs or 

potentially contaminated patient waste the following procedures must be followed. 

All such events/accidents should be reported to a senior member of staff and fully 

documented on a datix incident report form. 

Remove any contaminated clothing immediately. 

The contaminant must be removed as rapidly as possible by flushing the affected area 

with a large volume of cold water. If running water is not immediately available, bottles or 

bags of sterile water or normal saline should be kept as an alternative. 

After initial copious flushing with water, the contaminated skin should be thoroughly 

washed with liquid soap or antiseptic scrub and water. After rinsing, the process should 

be repeated. 

Shower facilities should be available for use if large areas of skin are contaminated. 

Do not use hand creams and emollients as these may aid absorption of the drug. 

Medical attention may be sought from the Accident & Emergency Department. 

A datix form must be completed, and the Head of Department & Occupational Health 

informed. 

Any contaminated clothing must be removed immediately. Put on gloves and an apron. 

Rinse the clothing under running tap water. Squeeze dry and place in a plastic bag. 



Uniforms or hospital linen contaminated with cytotoxic material should be placed in a red 

soluble- seamed bag, closed and then into a red material bag and a cytotoxic hazard 

label attached. . 

Personal clothing should be taken home for laundering. Such items should be laundered 

twice where possible. The first wash should be separate from other clothing. They may 

be laundered with other items for the second wash. 

Dispose of gloves and apron into a double yellow clinical waste bag. 

If there is a likelihood that the drug has soaked through the outer clothing, underwear 

must be removed and treated as above, and the area of skin treated as above. 

3.18.2 Eye contamination 

If contact occurs with the eyes the contaminant must be removed as rapidly as possible 

by flushing the eyes and surrounding areas with a large volume of sterile normal saline / 

water. Alternatively cold tap water can be used if necessary. 

Medical attention must be sought immediately from the Accident & Emergency 

Department. 

A datix incident report form must be completed and the Head of Department & 

Occupational Health informed. 

3.18.3 Needlestick injury 

In the event of a needlestick injury 

Allow the wound to bleed freely. 

Wash the puncture site/wound thoroughly with copious amounts of cold water. 

If the needle contained any cytotoxic drug contaminant, check the vesicant status of 

the drug by referring to the extravasation policy, or by seeking advice from a senior 

oncology or haematology pharmacist. 

Report the incident immediately to a senior member of staff. 

Follow the Trust‟s Needle stick injury procedure, and consider seeking advice from 

the Accident & Emergency Department or Occupational Health, especially if the 

needle had been in contact with a patient. 

3.18.4 Spillage 

A cytotoxic spillage kit must be available, at all times, in all clinical areas where cytotoxic 

drugs are administered, and in all pharmacy areas where cytotoxic drugs are handled or 

stored. All staff must know how to use it and where it is stored. If a kit is used it must be 

replaced immediately. At no times must access to a kit be impeded by blocking the 

surrounding area. 

Cytotoxic spillage kits are available from oncology pharmacy. 

In the event of a cytotoxic spillage 

Restrict access to the spillage area. 

Alert other members of staff in the vicinity and inform a senior member of staff. 

If you have been injured or contaminated, another member of staff must deal with the 

spillage while you receive attention for the injury or contamination following the 

procedure detailed in Section 3.18.1/2/3 

New and expectant mothers should not have direct involvement in the management 

of a cytotoxic spillage. 



Turn off all fans and reduce any draughts. 

Open a Cytotoxic Spillage Kit and follow the instruction within. 

If protective clothing has been contaminated during the spillage, remove the 

contaminated items and put on fresh protective clothing from the spillage kit. Place 

all contaminated items in the 'sharps' bin. 

The procedure as outlined in the pack should be followed. Such procedures should 

also be accessible in all relevant ward, clinic and pharmacy areas. 

SECTION 4 – TRAINING AND EDUCATION 

Training of all medical, nursing, pharmacy, portering, domestic and any other staff who 

handle cytotoxic drugs or cytotoxic waste is essential. Such staff should understand the 

potential hazards associated with cytotoxic drugs and be familiar with relevant procedures. 

4.1 Medical and Nursing Staff 

4.1.1 Oncology and Haematology Department 

Nursing and medical staff who are likely to be involved in the prescribing, preparation and/or 

administration of cytotoxic drugs should undergo the following initial training programme: 

Be familiar with all relevant local guidance. 

Be familiar with the national guidance and local policy on intrathecal chemotherapy and 

receive training on the administration of intrathecal chemotherapy where appropriate. 

This will include warning about the dangers of inadvertent administration of vinca 

alkaloids. 

Be familiar with local treatment protocols and information on the specific hazards 

associated with the drugs used. 

Have completed an agreed training programme and have had their competence 

assessed. 

Be familiar with the procedures for intravenous, oral and other routes of chemotherapy 

administration 

Be familiar with peripheral and central venous access devices, including line 

complications. 

Be familiar with mechanical pumps and other devices used for chemotherapy service 

delivery. 

Able to recognise signs and complications of myelosuppression. 

Be familiar with common chemotherapy side effects including nausea, vomiting, 

stomatitis, diarrhoea, phlebitis and alopecia. 

Be familiar with chemotherapy related oncological emergencies including extravasation, 

anaphylaxis and neutropenic sepsis. 

Be familiar with the 

Treatment of anaphylaxis. 

Treatment of extravasations of vesicant and non-vesicant agents. 

Management of anaphylaxis 

Management of neutropenic sepsis 

Be familiar with the procedure for handling cytotoxic spillages. 

Be aware of the location of information sources, and extravasation and spillage kits. 

Nursing staff who have not previously been competent in administering 

chemotherapy will attend a formal study day relating to chemotherapy administration. 

Following training, nursing staff will work through the agreed Anglia Cancer Network 

Chemotherapy Core Education Package with the assistance of their mentor They may 

not administer unsupervised until they have been assessed as competent using the 

agreed competencies. Once these have been signed off by their assessor a copy will 



e filled in the staff member‟s personal file and their name added to the 

chemotherapy competent register. 

Nursing staff who solely check chemotherapy will be required to complete modules 1-4 of the 

Anglia Cancer Network Chemotherapy Core Education Package. 

The chemotherapy competent register of named nursing staff who have been reviewed as 

competent to administer chemotherapy unsupervised is maintained and held within the 

Quality Manual. 

The roles of mentor and assessor are clearly defined within the Anglia Cancer Network 

Chemotherapy Core Education Package. 

The lead Chemotherapy Nurse will sign off assessors at band 7, thereafter the role of 

assessor will be undertaken by designated band 6 chemotherapy nurses, all assessors will 

be required to complete the competency for chemotherapy administering chemotherapy 

(NSW/REC/19) at assessor level. 

Nursing staff on the register will be asked to re confirm their competence annually 

and should attend a chemotherapy update session annually as well as completing the 

competency for administering chemotherapy (NSW/REC/19) and Nursing staff competencies 

(NSW/REC/10). 

The chemotherapy nurses based on Somersham ward are responsible for the 

chemotherapy education and training of ward based nursing staff and the outpatient 

matron is responsible for the education and training of outpatient based nursing staff . 

Areas administering cytotoxic agents outside of Oncology / Haematology will need to define 

the specific training requirements and competency levels of staff involved. 

4.1.2 Child Health 

Nurses and Medical staff must have attended the ACN training day and have 

completed the appropriate modules of the ACN Paediatric Chemotherapy education 

package for community and shared care. 

Medical staff involved in the prescribing of Paediatric regimens will receive further 

training from the PTC. 

The Paediatric Oncology training register of named nursing staff who have been 

reviewed as competent to administer chemotherapy unsupervised is maintained 

and held centrally on the communications drive and a hard copy maintained and kept 

in the Paediatric Oncology Office. 

4.2 Pharmacy Staff 

4.2.1 Handling 

Pharmacy staff who are involved in the handling of cytotoxic drugs e.g. receipt of goods, 

packaging, storage, transportation etc., must have their names entered on a central file at 

each Trust, having satisfactorily completed the following initial training programme: 

Read the sections in the cytotoxic guideline that are relevant to their work. 

Have received training and education on the health risks associated with handling 

cytotoxic drugs. 

Be familiar with local treatment protocols and information on the specific hazards 

associated with the drugs used. 



Read local pharmacy procedures and receive a practical demonstration of the relevant 

activities (such as dealing with a cytotoxic spillage), provided by the designated officer or 

the pharmacist acting under his / her authority. 

4.2.2 Preparation 

Professional and technical staff who are expected to participate in the preparation of 

parenteral cytotoxic drugs must be approved following the completion of the competency 

program. The pharmacy manager will maintain a register of approved staff and will ensure 

their training is updated at appropriate intervals. 

4.2.3 Clinical Screening of Chemotherapy Prescriptions 

Pharmacists who are involved in the clinical screening of chemotherapy prescriptions and/or 

provide a clinical pharmacy service to wards where Haematology/Oncology patients are 

cared for should undertake an additional training program. Only once assessed as 

competent, can prescriptions be checked unsupervised. 

4.2.4 Clinical screening and dispensing of Oral Chemotherapy Prescriptions 

Pharmacists who are involved in the clinical screening and dispensing of oral chemotherapy 

prescriptions should undertake an additional training program. Only once assessed as 

competent, can prescriptions be screened or dispensed doses checked unsupervised. 

4.3 Domestic Staff 

All domestic staff involved in cleaning duties in clinical areas should have received training 

and education on the health risks associated with cytotoxic drugs and cytotoxic waste, and 

the consequences of ineffective cleaning. 

4.4 Portering Staff 

All portering staff involved in transporting cytotoxic drugs should have received training and 

education on the health risks associated with cytotoxic drugs and cytotoxic waste. 

SECTION 5 – DEVELOPMENT AND IMPLEMENTATION INCLUDING 

DISSEMINATION 

Following approval this policy will be disseminated within the Oncology and Haematology 

directorate and other directorates involved in the administration of cytotoxic chemotherapy 

for cancer. It will also be placed on the intranet. 

The clinical practices in this policy were implemented following initial approval. Any change in 

clinical practice will be reflected in the updating of this policy in consultation with the 

Chemotherapy Working Group. 

SECTION 6 – MONITORING COMPLIANCE AND EFFECTIVENESS 

Adherence to this policy will be monitored by the Oncology and Haematology directorate as 

part of established governance arrangements. This includes review of clinical incidents 

relating to chemotherapy in both CST (Clinical Service Team) and Governance and 

Chemotherapy Working Group meetings. 

Ongoing clinical audit will also be utilised to measure compliance. 

The effectiveness of the policy will be subject to ongoing review by the Chemotherapy 

Working Group. 



SECTION 7 – CONTROL OF DOCUMENT INCLUDING ARCHIVING 

ARRANGEMENTS 

7.1 Once ratified by the Patient Safety Committee the Responsible Officer will forward 

this document to the Information Governance Department for a document index 

registration number to be assigned and for the document to be recorded onto the 

central hospital master index and central library of current documentation. 

7.2 In order that this document adheres to the hospital‟s Records Management Policy, 

the Information Governance Department will: 

Ensure that the most up-to-date version of this document is stored on the 

documentation library. 

Archive previous versions of this document. 

Retain previous versions of this document for a period of time in accordance with 

the NHS Records Retention and Disposal Schedule. 

This policy will be made available on the trust‟s intranet. 

The Oncology Matron is responsible for ensuring that this procedure adheres to the Trust‟s 

Record Management Policy, including retention and archiving arrangements. 

SECTION 8 – SUPPORTING COMPLIANCE AND REFERENCES 

As part of the Trust‟s networking arrangements and sharing best practice, the Trust supports 

the practice of sharing documents with other organisations. However, no document or part 

thereof so shared must be used by any third party for its own commercial gain. 

Release of any strategy, policy, procedure, guideline or other such material must be agreed 

with the Lead Director or Deputy/Associate Director (for Trust-wide issues) or Directorate/ 

Departmental Management Team (for Directorate or Departmental specific issues). Any 

requests to share this document must be directed in the first instance to Oncology Matron. If 

it is thought that the document may attract Intellectual Property rights, the advice of the 

Trust‟s Intellectual Property Lead should be sought. 

When the document is forwarded to another organisation, the Trust must give its express 

(i.e. written) permission for the document to be used by the requesting organisation which 

may only reproduce it internally within their own organisation for their own requirements. The 

requesting organisation may not forward it onto any other party. Ownership/copyright is 

acknowledged at the beginning of the document by including the phrase: 

"Reproduced with the kind permission of the (insert name) department, The Ipswich Hospital 

NHS Trust." 

Where Policy or any other document are used in clinical or other situations that might give 

rise to litigation the following phrase must also be inserted in the document and reemphasised 

in the covering letter to the requesting organisation: 

"The copyright of this document lies with The Ipswich Hospital NHS Trust and the author(s) 

as employee(s) are not liable for its contents. The Ipswich Hospital NHS Trust cannot be held 

responsible for any loss, damage or injury incurred by any individual or group using these 

Policy." 

Further advice is available from the Trust's Legal Services Manager. 



References 

1. Department of Health (2004) Manual for Cancer Services 

2. Department of Health (2008) HSC 2008/001 Updated national guidance on the safe 

administration of intrathecal chemotherapy 

3. HSE Information Sheet (2003) MISC 615. Safe handling of cytotoxic drugs 

4. Practice for the Safe Handling of Cytotoxic Drugs in Pharmacy Departments. Aud J 

Hospital Pharm. 1999; 29 (2): 108-116 

5. Risk Assessment Requirements. HSE. 

6. COSHH Regulations 2002. HSE. 

7. March guidelines (www.marchguidelines.com) 

8. Good Practice in Consent (2001), HSC 200/023 

9. Mallet J and Dougherty L (ed) (2000). Manual of clinical nursing procedures fifth edition. 

The Royal Marsden Hospital. Blackwell Science. 

10. Standards for Infusion Therapy. Royal College of Nursing. October 2003. 

11. Antunes G et al. BTS Guidelines for the Management of Malignant Pleural Effusions. 

Thorax 2003 (Suppl II):ii29-ii38. 

12. Dougherty L (1999) Safe handling and administration of intravenous cytotoxic drugs. In 

Dougherty L, Lamb J (1 st ed.) Intravenous therapy in nursing practice. Edinburgh: 

Churchill Livingston. Chapter 16. 

13. Allwood M, Stanley A, Wright P (2002) The Cytotoxics Handbook 4 th ed. Radcliffe 

Medical Press. ISBN 1 857775 504 

14. Gault D T (1993) Extravasation injuries. British Journal of Plastic Surgery March: 46 

(2):1991-1996. 

15. Stamford B L & Hardwicke F. A Review of Clinical Experience with Paclitaxel 

Extravasations. Support Care Cancer (2003) 11; 270-277 

16. Mourisden H.T. et al Ann Oncol doi: 10.1093/annonc/mdl413 

17. For better, for worse A review of the care of patients who died within 30 days of 

receiving systemic anti-cancer therapy. National Confidential Enquiry into patient 

outcome and death, 2008. 

18. Chemotherapy Services in England: Ensuring quality and safety. A report from the 

National Chemotherapy Advisory Group, 2008. 

19. National Patient Safety Agency Rapid Response Report, 2008, RRR004, Using Vinca 

Alkaloid mini bags (Adult / Adolescent units) 11 th August 2008. 

20. National Patient Safety Agency, 2008, RRR001. Risks of incorrect dosing of oral anticancer 

medication.

Chemotherapy Policy - Ipswich Hospital

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