Medication checks 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. Antineoplastic 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 guidelinesr outline the specific checks that should be performed prior to administration of antineoplastic 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 antineoplastic 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.
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:
- 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 Antineoplastic drug administration time out checklist.
Oral antineoplastic drug administration
© Cancer Institute NSW 2011
Oral antineoplastic 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, carers and family members and all members of the multidisciplinary team require specific education to ensure safety.r
- Do not
- break or crush oral antineoplastic tablets
- open oral antineoplastic capsules
- The patient should be instructed about how to take their oral antineoplastic drug and advised to swallow the table or capsule whole and not chew
- selected 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 antineoplastic 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.
- All unused tablets and capsules should be returned to the pharmacy department.
Read more about oral antineoplastic drug administration.
Intramuscular (IM) and subcutaneous (subcut) antineoplastic drug administration
- All drugs should be stored appropriately prior to administration as directed by the pharmacist.
- All syringes should be checked prior to use for any leakage or contamination.
- Do not expel air from syringes.
- Select an appropriate site for administration
- if frequent injections are given, rotate the injection site.
- Appropriate personal protective equipment (PPE) should be worn by personnel administering antineoplastic drugs.
- Patients should be monitored for signs and symptoms of a hypersensitivity reaction. Refer to local policies and guidelines for further information.
- Unused drugs should be returned to the pharmacy.
- When administering IM or subcut injections to paediatric patients do not administer subcutaneous antineoplastic drugs through an Insuflon.
Read more about intramuscular and subcutaneous antineoplastic drug administration.
Intravenous antineoplastic drug administration
Intravenous antineoplastic drugs may be administered through a central venous access device (CVAD) or peripheral cannula. Administration may be via bolus injection, intermittent infusion or continuous infusion as determined by the treatment protocol.
Before commencing antineoplastic therapy, the patient's venous access requirements should be assessed according to the requirements of the treatment protocol, the patient’s peripheral vasculature and personal preference. Throughout all antineoplastic drug administration the patient should be monitored for signs and symptoms of hypersensitivity reactions.
It is important to check:
- The treatment protocols for specific requirements e.g. assessments, monitoring, pre-medications, antiemetics or fluids, before administering antineoplastic drugs.
- All drugs are stored appropriately as directed by pharmacy.
- All syringes and infusion bags before use for any leakage, 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.
- Appropriate personal protective equipment (PPE) is worn by personnel administering antineoplastic drugs.
- The order of drug administration - antineoplastic drugs are administered in the following order unless otherwise indicated by the specific treatment protocol:
- vesicant drugs,
- irritants with vesicant properties,
- irritants, and then
- Closed system intravenous administration sets with luer lock fittings should be used for administration of antineoplastic therapy.
- Unused drugs should be returned to the pharmacy.
Intravenous cannula (IVC)
- Vesicant drugs should be administered through a newly sited cannula NSW Health Policy Standard 2015 '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.
- cannulating the back of hand, joints and the antecubital fossa
- the arm on the side of an axillary lymph node dissection
- cannulating 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 then a site in the same vein may be selected but it MUST be proximal to the previous puncture.
- 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)
- Stabilise and secure the CVAD with a transparent dressing to allow the site to be visualised.
- Access CVAD using local hospital policy and guidelines.
- Select an appropriate needle size for implanted venous ports (IVP).
- Confirm the patency of the CVAD by withdrawing blood and then flushing with 5 to 10 mL sodium chloride 0.9% or other compatible fluid.
- Do not use if resistance, pain or discomfort is felt to the flow of fluid - refer to a senior nurse and/or medical officer for guidance.
Specific considerations for vesicant antineoplastic 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 by injection into a side port of a fast running drip or via a minibag.
- DO NOT inject against resistance
- if administration is via a CVAD, do not proceed without a full review of the CVAD and/or radiologic confirmation of patency.
- DO NOT use a pump to administer vesicants
- administer by free flow using gravity
- NOTE: for paediatric patients refer to local policy and guidelines when using infusion pumps to administer vesicant antineoplastic 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
- If any doubt do not proceed with administration, review and manage appropriately.
Read more about intravenous antineoplastic drug 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"