What precautions are taken by the nurse when administering antineoplastic medications?

Purpose/Objectives: To develop and test a worksite intervention that protects healthcare workers who handle antineoplastic drugs from work-related exposures.

Design: Intervention study.

Setting: A university hospital in a large midwestern metropolitan area and its outpatient chemotherapy infusion clinic.

Sample: 163 staff (nurses, pharmacists, and pharmacy technicians) who work with antineoplastic agents.

Methods: A self-report survey measured workplace and individual factors to assess use of personal protective equipment (PPE). Wipe samples were tested for surface contamination. An intervention incorporating study findings and worker input was developed.

Main Research Variables: PPE use was the dependent variable, and the independent variables included knowledge of the hazard, perceived risk, perceived barriers, interpersonal influence, self-efficacy, conflict of interest, and workplace safety climate.

Findings: PPE use was lower than recommended and improved slightly postintervention. Self-efficacy and perceived risk increased on the post-test survey. Chemical residue was found in several areas. Awareness of safe-handling precautions improved postintervention. The unit where nurses worked was an important predictor of safety climate and PPE use on the pretest but less so following the intervention.

Conclusions: Involving staff in developing an intervention for safety ensures that changes made will be feasible. Units that implemented workflow changes had decreased contamination.

Implications for Nursing: Worksite analysis identifies specific targets for interventions to improve antineoplastic drug handling safety.

Not a current ONS member or journal subscriber?

Receive a PDF to download and print.

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. 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 guidelinesr 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.

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 Anti-cancer drug administration time out checklist.

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, 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 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 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.
• All unused tablets and capsules should be returned to the pharmacy department.

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 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 anti-cancer 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 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 infusion 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:

• 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.
• 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 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:
  • vesicant drugs,
  • irritants with vesicant properties,
  • irritants, and then
  • neutrals.

General considerations

• Closed system intravenous administration sets with luer lock fittings should be used for administration of anti-cancer 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 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 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.
• 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 using 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 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 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 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 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 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"

What are the precautions to be taken by the nurses when preparing and administering the chemotherapy drugs on the patient?

What special precautions should the nurse use when handling and administering chemotherapeutic agents?

What should the nurse do before administering chemotherapy?

What is the most common and potentially serious complication of antineoplastic medications?