Safe administration of anti-cancer drugs

The purpose of this document is to provide information on the safe administration of anti-cancer drugs. Only healthcare professionals who have attained competency as per institutional guidelines should administer anti-cancer drugs. Errors in prescribing, dispensing and administration of anti-cancer drugs can result in patient harm.^rr To reduce the risk of errors, it is important to follow all policies and procedures.

This document should be read in conjunction with:

•  Clinical Oncological Society of Australia (COSA) 2017 Guidelines for the Safe Prescribing, Dispensing and Administration of Cancer Chemotherapy 
• eviQ clinical resource document - Safe handling and waste management of hazardous drugs 

Patient education

Before administering anti-cancer drugs, patients and carers should receive appropriate education, including both written and verbal information on:

• the treatment process, including:
  • treatment protocol - including anti-cancer drugs and supportive medications
  • route(s) of administration
  • venous access requirements 
  • blood tests and other treatment-related investigations
  • follow up appointments
• the potential for side effects
• management of side effects
  • self-care measures
  • situations that require urgent attention
• handling anti-cancer drugs and related waste safely.

The use of a written checklist such as the eviQ Anti-cancer drug patient education checklist might be useful to ensure that all important points are covered. The checklist can also be used to document that education has taken place and the topics covered.

Patient consent

Informing patients and obtaining consent in regard to specific treatment is a legal requirement - see your local policies for further information and guidance.^rrr The role of informed consent is to ensure patients, carers and family members understand the purpose, benefits, and risks of all treatment options before consenting or declining treatment. Where the patient is unable to provide consent themselves, consent can be obtained from a parent, legal guardian or power of attorney.

Patient assessment

Before commencing anti-cancer treatment all patients should have a baseline clinical, physical and psychosocial assessment. Any other investigations as specified by their treatment protocol should also be completed and reported on before administering anti-cancer drugs.

Baseline assessment should include:^r

• height and weight should be measured for body surface area (BSA) to be calculated
• performance status using the Eastern Cooperative Oncology Group (ECOG) Performance Status for adult patients or Lansky Play-Performance Scale for patients under 16 years of age^r
• blood tests as indicated by the treatment protocol
• scans or investigations as indicated by the treatment protocol (e.g. lung functions tests, gated heart pool, ECHO, audiology)
• vital signs
• allergy and drug reaction history.

Ongoing assessment should include:

• vital signs
• blood tests
• assessment of treatment related side effects and/or toxicities 
• performance status
• weight
• paediatric patients require measurement of height and weight for recalculation of BSA as per local policies and guidelines
• psychosocial assessment
• any protocol specific investigations outlined within the treatment protocol (i.e. lung function tests, gated heart pool scan).

The use of an assessment tool such as the eviQ Anti-cancer drug patient assessment tool provides a checklist to assist the patient assessment. 

Other assessment tools are also available via eviQ which may assist in assessing specific toxicities, for example, the Oral mucositis assessment tool and the Chemotherapy induced peripheral neuropathy screening tool. Any identified toxicity equal or greater than grade 2 should be assessed by a medical officer before commencing treatment.

Safe handling precautions

Appropriate personal protective equipment (PPE) should be worn for administration of all anti-cancer therapy. For detailed information regarding safe handling of hazardous drugs and associated waste, see the eviQ Safe handling and waste management of hazardous drugs document.

Medication checks, patient identification and time out procedure

All drugs MUST be checked at the point of administration by two appropriately trained and skilled registered nurses. Where a second nurse is unavailable, an appropriately trained pharmacist or a medical officer can perform this function. Anti-cancer drug prescription charts should outline all treatment information associated with the treatment protocol, including supportive therapies, in a clear, consistent and unambiguous manner. The height and weight of the patient should be documented, and the BSA recalculated using the same method of calculation to ensure accuracy. Drug doses should be calculated against the dosing requirements (BSA, AUC, mg/kg) to ensure the correct doses have been prescribed and dispensed.

The COSA guidelines^r outline the specific checks that should be performed prior to administration of anti-cancer drugs:

• The protocol - verify the prescription is in accordance with the treatment protocol, including correct patient parameters, correct doses, completed investigations and pre and post-supportive medications.
• Scheduling - ensure the appropriate time period has passed since the last dose of anti-cancer drugs.
• Route of administration - ensure this has been documented for each drug to be administered.
• Rate of administration - verify the rate has been specified and is correct for each medication.
• Adverse drug reactions - ensure all allergies or history of hypersensitivity are clearly documented.

Positive patient identification (PPID) checks must occur prior to the administration of anti-cancer therapy to minimise patient safety risks that occur with a patient-treatment mismatch.^r Individual patient identification and procedure matching requires the use of at least three approved patient identifiers when providing care, therapy or services. Approved patient identifiers may include:

• patient name (family and given names)
• date of birth
• address
• medical record number
• Individual Healthcare Identifier.

The term ‘Time out’ is taken from the World Health Organisation Surgical Safety checklist and has been implemented in many medical areas. COSA describes the ‘Time out’ check as a final patient safety check to be undertaken immediately prior to commencing drug administration and should encompass:^r

• correct patient
• correct drug
• correct dose
• correct route
• correct time.

The medication check must be verified by both health professionals signing and dating the medication chart. The 'Time out' procedure should be documented in the patient’s notes or via a specific Time out checklist such as the  Anti-cancer drug administration time out checklist.

Prior to administration of anti-cancer drugs, it is important to check:

• The treatment protocols for specific requirements, e.g. assessments, monitoring, pre-medications, antiemetics or fluids, before administering anti-cancer drugs
• All drugs are stored appropriately as directed by pharmacy
• Appropriate personal protective equipment (PPE) is worn by personnel administering anti-cancer drugs
• The order of drug administration - anti-cancer drugs are administered in the following order unless otherwise indicated by the specific treatment protocol:
  1. vesicant drugs
  2. irritants with vesicant properties
  3. irritants
  4. neutrals

Following treatment, unused drugs should be returned to the pharmacy.

Oral anti-cancer drug administration

© Cancer Institute NSW 2011

Oral anti-cancer drugs carry the same risk of toxicity and medication errors as those given via other routes. As these drugs are often administered in the community, patients, their carers and family members, and all members of the multidisciplinary team require specific education to ensure safety.^r

• Do not
  • break or crush oral anti-cancer tablets 
  • open oral anti-cancer capsules
• The patient should be instructed about how to take their oral anti-cancer drug and advised to swallow the tablet or capsule whole and not chew
  • select oral targeted therapies can be dispersed in water; refer to the pharmacist or product information for specific instructions
• If a patient is unable to swallow the tablet or capsule, the pharmacist must be contacted for advice on alternative medication formulations or administration routes
• Capsules and coated tablets should be administered using chemoprotectant gloves and the 'non-touch technique'
• Uncoated tablets and liquid formulations are administered using full personal protective equipment (PPE)
• All oral anti-cancer drugs are administered using non-touch technique
• Contact the medical officer for further advice and guidance if the patient:
  • vomits after administration
  • forgets to take their prescribed dose
• All tablets and capsules should be stored appropriately as directed by a pharmacist

Read more about oral anti-cancer drug administration.

Information on oral formulations, including images, is available from the product information and eMIMs, including Pill Identifier function.

Intramuscular (IM) and subcutaneous (subcut) anti-cancer drug administration

• All syringes should be checked prior to use for any leakage, unexpected cloudiness or signs of precipitation or contamination
• Do not expel air from syringes
• Select an appropriate site for administration
  • if frequent injections are given, rotate the injection site
• Patients should be monitored for signs and symptoms of a hypersensitivity reaction. Refer to local policies and guidelines for further information
• When administering IM or subcut injections to paediatric patients do not administer subcutaneous anti-cancer drugs through an Insuflon

Read more about intramuscular and subcutaneous anti-cancer drug administration.

Intravenous anti-cancer drug administration

© Cancer Institute NSW 2019

Intravenous anti-cancer drugs may be administered through a central venous access device (CVAD) or peripheral cannula. Administration may be via bolus injection, intermittent or continuous infusion as determined by the treatment protocol.

Before commencing anti-cancer therapy, the patient's venous access requirements should be assessed according to the requirements of the treatment protocol, the patient’s peripheral vasculature, lymphoedema history or risk and personal preference. Throughout all anti-cancer drug administration, the patient should be monitored for signs and symptoms of hypersensitivity reactions.

It is important to:

• Check all syringes and infusion bags before use for any leakage, unexpected cloudiness or signs of precipitation or contamination
  • Some preparations may require gentle agitation to mix prior to administration to ensure an even dispersion of drug in the diluent, as medication can settle on storage.
• Use closed-system intravenous administration sets with luer lock fittings for administration of anti-cancer therapy

Intravenous cannula (IVC)

• Vesicant drugs should be administered through a newly sited cannula  NSW Health Policy Standard 2020 'High Risk Medicines Management'
• Non-vesicant drugs can be administered through a cannula that has not been in situ for more than 48 hours
• Choose an appropriate IVC type and size for the type of treatment and patient's veins - where possible, use a large vein in the middle of the forearm
• Avoid cannulating
  • the back of hand, joints, points of flexion and the antecubital fossa
  • the arm on the side of an axillary lymph node dissection
  • veins that have been recently used as there is an increased risk of extravasation of the drug from the old site; use a different vein, preferably on the opposite limb. If this is not possible, a site in the same vein may be selected, but it MUST be proximal to the previous puncture site
• Ensure
  • the IVC is stabilised and secured with a transparent dressing to allow the site to be visualised
  • patency of the IVC by checking:
    • no resistance is felt when injecting fluid into the cannula
    • for blood return before connecting the closed system and frequently throughout the administration - do not disconnect the closed system
    • the intravenous infusion flows freely once connected
  • a new IVC must be inserted if the IVC is not patent or resistance is felt

Central venous access device (CVAD)

• Access CVAD as per local hospital policy and guidelines
• Stabilise and secure the CVAD with a transparent dressing to allow the site to be visualised
• Select an appropriate needle size for implanted venous ports (IVP)
• Once the CVAD is accessed, confirm patency by withdrawing blood and flushing with 5 to 10 mL sodium chloride 0.9% or other compatible fluid
• Do not use if resistance, pain or discomfort is felt during the flow of fluid - refer to a senior nurse and/or medical officer for guidance and review

Specific considerations for vesicant anti-cancer drugs

• If there is more than one vesicant drug, administer DNA binding drugs first, followed by non-DNA binding drugs, e.g. anthracyclines followed by vinca alkaloids
• During the administration of a vesicant drug:
  • for bolus infusions, staff should remain at the patient's side during the entire administration
  • for extended infusions, staff should regularly check the patient as per local policy and guidelines
  • for adult patients, vesicant drugs should be diluted during administration; administer via a mini bag OR by IV bolus via a side port of a free-flowing IV infusion
• DO NOT inject against resistance
  • if administration is via a CVAD, do not proceed without a full review of the CVAD and/or radiologic confirmation of patency
• DO NOT use a pump to administer vesicants
  • administer by free flow using gravity
  • NOTE: for paediatric patients, refer to local policy and guidelines when using infusion pumps to administer vesicant anti-cancer drugs
• Check line patency and blood return regularly throughout the drug administration
• Monitor the site for signs of extravasation or leakage
• If extravasation is suspected, STOP the infusion:
  • inspect the venous access device (VAD) for blood return, and
  • inspect the insertion site for signs of leakage or oedema
• Educate the patient and carers to immediately report symptoms such as pain, burning, stinging, swelling, or erythema during and after administration
• Extravasation must be managed immediately to minimise tissue necrosis
  • Read more about Extravasation management.
• If there is any doubt, do not proceed with administration; review and manage appropriately

Read more about intravenous anti-cancer drug administration

Vincristine administration

Vincristine (a vinca alkaloid and vesicant) must only be administered intravenously. Sentinel events resulting in permanent disability or death from inadvertent intrathecal administration of vinca alkaloids are well documented.^r

Link to   Safety and Quality Council 2005. Safety alert - vincristine

• Vincristine must be supplied in an infusion bag. The minimum recommended volume for adult patients is 50 mL to be administered over 5 to 10 minutes.
• Volume for paediatric patients varies between 20 to 50 mL depending on age and weight of patient. Vincristine is to be administered over 5 to 10 minutes or as indicated in the treatment protocol.
• Distinctive warning labels must be placed on all vincristine preparations: "FOR INTRAVENOUS USE ONLY - Fatal if given by other routes"

• Ensure administration of post-therapy fluids and medications are given as per protocol requirements; for example, folinic acid rescue, steroids and antiemetics
• Monitor and assess patients as per protocol requirements
• Arrange relevant laboratory tests and provide patient with appropriate forms
• Ensure an appointment for medical review and the sunsequent treatment cycle is booked
• Refer to community nurse if required
• Ensure patient has all discharge medications
• Provide patient with neutropenic sepsis and/or immunotherapy alert card or letter if appropriate
• Ensure the patient has been provided with written information about the treatment administered, including expected side effects, precautions to be taken and what to do in the event of adverse effects, e.g. uncontrolled nausea and vomiting or severe diarrhoea
• Provide emergency contact details for medical staff and treatment centre, particularly for ‘out of hours’ and/or local emergency contact for rural and regional patients

Document in the patient notes:

• patient and carer education
• patient assessment
• venous access device used and any considerations/complications
• record of drug administration
• any adverse events and the interventions, e.g. dose reductions
• patient referrals.

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