Summary of recommendations

From Cancer Guidelines Wiki


Recommendations

General Information

What competencies and skills are required for the safe provision of cancer therapy?

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Each healthcare facility should establish a process to ensure that designated personnel have been trained and authorised to prescribe, dispense and administer cancer therapies as a treatment modality. Mechanisms should be in place to ensure appropriate training and supervision of inexperienced staff and trainees.


All staff involved in the management of cancer and cancer therapy must be competent to perform their relevant functions. In this context, competency should be measurable as an indicator of actual ability to perform defined duties and should be re-assessed at appropriate intervals.


All staff should maintain an appropriate knowledge and skill base with processes in place to ensure continuing professional education. Table 1 provides a suggested list of essential knowledge.


If a facility introduces a new model of service delivery, a new resource (e.g. electronic prescribing) or a new treatment protocol then a process should be in place to ensure upskilling and competency of staff to deliver the service or treatment.

  • Clinical_question:What competencies and skills are required for the safe provision of cancer therapy?#Practice_point_1
  • Each healthcare facility should establish a process to ensure that designated personnel have been trained and authorised to prescribe, dispense and administer cancer therapies as a treatment modality. Mechanisms should be in place to ensure appropriate training and supervision of inexperienced staff and trainees.

All staff involved in the management of cancer and cancer therapy must be competent to perform their relevant functions. In this context, competency should be measurable as an indicator of actual ability to perform defined duties and should be re-assessed at appropriate intervals.


All staff should maintain an appropriate knowledge and skill base with processes in place to ensure continuing professional education. Table 1 provides a suggested list of essential knowledge.


If a facility introduces a new model of service delivery, a new resource (e.g. electronic prescribing) or a new treatment protocol then a process should be in place to ensure upskilling and competency of staff to deliver the service or treatment.

  • Consensus based recommendation
Practice pointQuestion mark transparent.png

Staff should have equitable access to education and training resources to develop and maintain their competency and skills.


Resources and training should ensure staff develop and maintain both clinical and behavioural skills relevant to cancer therapy (e.g. communication skills).


Experienced and senior staff who are competent in the management of cancer therapy should facilitate appropriate training and learning opportunities.


Education programs should have clear and unambiguous learning objectives, be useable and enable regular competency assessment. Programs should be discipline specific where appropriate (Goldspiel et al, 2015).


Training in electronic management systems used in cancer must be provided to all staff. An assessment of user competency should be performed before system access is granted to prescribe, dispense or administer cancer therapy.


Education and training should include applicable standards and legislation from local, state and national bodies (Vioral, 2014).


Members of the multidisciplinary team that are involved in the prescribing, dispensing and administration of cancer therapy should collaborate to identify the key characteristics of an assessor. For example; minimum years of experience, completion of a program related to conducting assessments, advanced communication skills.


Staff involved in the patient's care should be easily identifiable to the patient according to the discipline and speciality they represent (e.g. nursing, pharmacy, medical and pathology staff). This is to ensure the patient can direct questions about their cancer treatment to the most appropriately skilled person. Students and trainees must be identified to the patient.

  • Clinical_question:What competencies and skills are required for the safe provision of cancer therapy?#Practice_point_2
  • Staff should have equitable access to education and training resources to develop and maintain their competency and skills.

Resources and training should ensure staff develop and maintain both clinical and behavioural skills relevant to cancer therapy (e.g. communication skills).


Experienced and senior staff who are competent in the management of cancer therapy should facilitate appropriate training and learning opportunities.


Education programs should have clear and unambiguous learning objectives, be useable and enable regular competency assessment. Programs should be discipline specific where appropriate (Goldspiel et al, 2015).


Training in electronic management systems used in cancer must be provided to all staff. An assessment of user competency should be performed before system access is granted to prescribe, dispense or administer cancer therapy.


Education and training should include applicable standards and legislation from local, state and national bodies (Vioral, 2014).


Members of the multidisciplinary team that are involved in the prescribing, dispensing and administration of cancer therapy should collaborate to identify the key characteristics of an assessor. For example; minimum years of experience, completion of a program related to conducting assessments, advanced communication skills.


Staff involved in the patient's care should be easily identifiable to the patient according to the discipline and speciality they represent (e.g. nursing, pharmacy, medical and pathology staff). This is to ensure the patient can direct questions about their cancer treatment to the most appropriately skilled person. Students and trainees must be identified to the patient.

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What resources are required for the safe provision of cancer therapy?

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Staff numbers and skill mix must be suitable for the activity and cancer type. Staffing resources should take into account the range of tumour groups treated, the complexity of the treatment, the case mix and number of patients that attend the facility for treatment and/or management of side effects from cancer therapy.


Electronic information management systems should be in place to support the provision of cancer therapy. Systems for prescribing, dispensing and administration should provide seamless data entry or be linked to minimise the need to duplicate data entry.


Up-to-date information resources that support the delivery of cancer therapy must be available to all staff at the point of care. With the frequency that new cancer treatments and protocols evolve it is recommended that electronic reference resources be utilised to inform day-to-day practice.


All staff should have access to up-to-date and well maintained equipment (e.g. computers, infusion pumps) to support the delivery of cancer therapy.

  • Clinical_question:What resources are required for the safe provision of cancer therapy?#Practice_point_1
  • Staff numbers and skill mix must be suitable for the activity and cancer type. Staffing resources should take into account the range of tumour groups treated, the complexity of the treatment, the case mix and number of patients that attend the facility for treatment and/or management of side effects from cancer therapy.

Electronic information management systems should be in place to support the provision of cancer therapy. Systems for prescribing, dispensing and administration should provide seamless data entry or be linked to minimise the need to duplicate data entry.


Up-to-date information resources that support the delivery of cancer therapy must be available to all staff at the point of care. With the frequency that new cancer treatments and protocols evolve it is recommended that electronic reference resources be utilised to inform day-to-day practice.


All staff should have access to up-to-date and well maintained equipment (e.g. computers, infusion pumps) to support the delivery of cancer therapy.

  • Consensus based recommendation
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Labour resources


A process should be in place for capacity management to ensure staffing resources match patient activity and treatment complexity.


A structured peer support or mentoring program should be available to all staff new to cancer or new to the facility (Ashley et al, 2011).


Specialist populations (e.g. geriatrics, paediatrics and patients undergoing stem cell transplant) require a reduced staff-to-patient ratio to ensure safe practices can be maintained. It is recommended that transplant facilities follow the 'Foundation for the Accreditation of Cellular Therapy' (FACT) accreditation standards.


Staffing resources should include skilled Information Technology (IT) support to manage implementation and maintenance of electronic prescribing systems.


Non labour resources


All staff must have easy access to up-to-date information resources to support their role. Minimum resources that should be available include:

  • Online resources and medication information that provides specialist information on chemotherapy administration, compatibilities, toxicities and monitoring and supportive care.
  • Up-to-date protocols and journal articles relating to treatment, e.g. eviQ Cancer Treatments Online (Cancer Institute NSW).
  • Out-of-date text books and printed resources can compromise patient safety where information has been superseded. It is recognised that some older text books and protocols may be useful in specific cases and for educational purposes. They should be kept in a designated area and clearly annotated where the information has been superseded.
  • Clinical_question:What resources are required for the safe provision of cancer therapy?#Practice_point_2
  • Labour resources

A process should be in place for capacity management to ensure staffing resources match patient activity and treatment complexity.


A structured peer support or mentoring program should be available to all staff new to cancer or new to the facility (Ashley et al, 2011).


Specialist populations (e.g. geriatrics, paediatrics and patients undergoing stem cell transplant) require a reduced staff-to-patient ratio to ensure safe practices can be maintained. It is recommended that transplant facilities follow the 'Foundation for the Accreditation of Cellular Therapy' (FACT) accreditation standards.


Staffing resources should include skilled Information Technology (IT) support to manage implementation and maintenance of electronic prescribing systems.


Non labour resources


All staff must have easy access to up-to-date information resources to support their role. Minimum resources that should be available include:

  • Online resources and medication information that provides specialist information on chemotherapy administration, compatibilities, toxicities and monitoring and supportive care.
  • Up-to-date protocols and journal articles relating to treatment, e.g. eviQ Cancer Treatments Online (Cancer Institute NSW).
  • Out-of-date text books and printed resources can compromise patient safety where information has been superseded. It is recognised that some older text books and protocols may be useful in specific cases and for educational purposes. They should be kept in a designated area and clearly annotated where the information has been superseded.
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What governance processes, policies and procedures should be in place for the safe provision of cancer therapy?

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Each healthcare facility should have its own governance committee and framework to provide direction and clear instruction on working practices for all team members involved in the delivery of cancer medications. The clinical governance committee should include consumer input.


Policies and procedures should be approved by a relevant governance committee, which may include the facilities Drug and Therapeutics Committee. All documents must include a specified review date and mechanisms must be in place to update procedures and policies regularly.


All team members should have access to and be familiar with the content of the policies and procedures including updated versions.


A mechanism should be in place that enables regular review and audit of practices and encourages a culture of continuous safety and quality improvement.

  • Clinical_question:What governance processes, policies and procedures should be in place for the safe provision of cancer therapy?#Practice_point_1
  • Each healthcare facility should have its own governance committee and framework to provide direction and clear instruction on working practices for all team members involved in the delivery of cancer medications. The clinical governance committee should include consumer input.

Policies and procedures should be approved by a relevant governance committee, which may include the facilities Drug and Therapeutics Committee. All documents must include a specified review date and mechanisms must be in place to update procedures and policies regularly.


All team members should have access to and be familiar with the content of the policies and procedures including updated versions.


A mechanism should be in place that enables regular review and audit of practices and encourages a culture of continuous safety and quality improvement.

  • Consensus based recommendation
Practice pointQuestion mark transparent.png

Policies and procedures should be stored electronically in a read-only format to avoid unapproved or undetectable alterations.


Printing copies of procedures and protocols that are available electronically should be minimised with staff encouraged to use electronic sources. This avoids the possible use of superseded documents when a newer version is issued. Any printed material should be annotated with the date of printing. A useful statement to add as a footnote is: All printed copies of this document are considered uncontrolled copies. Printed copies are only valid for the day printed.


When policies and procedures are being circulated for update or review the document should be annotated with a watermark to clearly identify that it has not been approved.

  • Clinical_question:What governance processes, policies and procedures should be in place for the safe provision of cancer therapy?#Practice_point_2
  • Policies and procedures should be stored electronically in a read-only format to avoid unapproved or undetectable alterations.

Printing copies of procedures and protocols that are available electronically should be minimised with staff encouraged to use electronic sources. This avoids the possible use of superseded documents when a newer version is issued. Any printed material should be annotated with the date of printing. A useful statement to add as a footnote is: All printed copies of this document are considered uncontrolled copies. Printed copies are only valid for the day printed.


When policies and procedures are being circulated for update or review the document should be annotated with a watermark to clearly identify that it has not been approved.

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What are the documentation requirements to support the safe provision of cancer therapy?

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All documentation must be legible and organised in a standardised format.


Important and variable patient data that may be used to inform treatment decisions and clinical verification of therapy should be made available to all staff in a timely, easy to read manner (e.g. weight, laboratory results). Where electronic systems are used to obtain and store information, procedures should be in place for storage and access of information.


Local policies should be in place to ensure that when a patient's care is transferred to another setting, all relevant documentation pertaining to that patient’s treatment is transmitted accurately and patient confidentiality is protected (Neuss et al, 2017; Goldspiel et al, 2015).


A standardised clinical handover process and documentation for patients receiving cancer therapy should be adopted (Australian Commission on Safety and Quality in Health Care, 2012).

  • Clinical_question:What are the documentation requirements to support the safe provision of cancer therapy?#Practice_point_1
  • All documentation must be legible and organised in a standardised format.

Important and variable patient data that may be used to inform treatment decisions and clinical verification of therapy should be made available to all staff in a timely, easy to read manner (e.g. weight, laboratory results). Where electronic systems are used to obtain and store information, procedures should be in place for storage and access of information.


Local policies should be in place to ensure that when a patient's care is transferred to another setting, all relevant documentation pertaining to that patient’s treatment is transmitted accurately and patient confidentiality is protected (Neuss et al, 2017; Goldspiel et al, 2015).


A standardised clinical handover process and documentation for patients receiving cancer therapy should be adopted (Australian Commission on Safety and Quality in Health Care, 2012).

  • Consensus based recommendation
Practice pointQuestion mark transparent.png

Protocols, procedures and other documentation templates that are stored electronically should be in a read-only format to avoid unapproved or undetectable alterations that could lead to errors. Access to original clinical protocols and templates should be restricted to named, authorised staff.


Printing copies of procedures and protocols that are available electronically should be minimised. This can lead to out-of-date information being accessed and incorrect procedures being utilised. A useful statement to add as a footnote is: All printed copies of this document are considered uncontrolled copies. Printed copies are only valid for the day printed.


The printing of patient relevant documentation that is stored electronically should be minimised unless essential to inform a patient healthcare record or to provide information to the patient.

  • Clinical_question:What are the documentation requirements to support the safe provision of cancer therapy?#Practice_point_2
  • Protocols, procedures and other documentation templates that are stored electronically should be in a read-only format to avoid unapproved or undetectable alterations that could lead to errors. Access to original clinical protocols and templates should be restricted to named, authorised staff.

Printing copies of procedures and protocols that are available electronically should be minimised. This can lead to out-of-date information being accessed and incorrect procedures being utilised. A useful statement to add as a footnote is: All printed copies of this document are considered uncontrolled copies. Printed copies are only valid for the day printed.


The printing of patient relevant documentation that is stored electronically should be minimised unless essential to inform a patient healthcare record or to provide information to the patient.

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What information should be included in a treatment protocol for cancer therapy?

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The protocol should come from an evidence-based, published source or validated standard reference source such as the Australian government’s eviQ Cancer Treatments online resource (Cancer Institute NSW) or Children’s Oncology Group (COG) wherever possible. The use of an abstract, which does not represent full results/analysis, should be discouraged as a direct source for writing a chemotherapy order unless an exceptional case arises (Carrington et al, 2010).


There should be a formalised process of initial review by a multidisciplinary team before a protocol is implemented into clinical practice (Carrington et al, 2010). The responsibilities of each member of the team in verifying the content of a protocol should be clearly defined.


Protocols agreed within an institution should be incorporated into an electronic program (e.g. an oncology information system or computerised prescribing system). A fully validated electronic prescribing system should be utilised for the prescribing of chemotherapy wherever available (National Chemotherapy Advisory Group, 2009). Where an electronic system is not available pre-printed prescriptions should be used.


Investigational medications, doses and administration schedules must be verified against a study protocol that has been approved by all relevant regulatory agencies and study sponsors. Any protocol amendments should be distributed immediately and an up-to-date copy of the study protocol should be readily available for reference (Goldspiel et al, 2015).


Requirements associated with the delivery of the protocol at a local level should be considered including availability of supportive services (e.g. pathology and the ability to manage expected adverse effects or events) (Carrington et al, 2010).


Protocols should be reviewed on a regular basis for currency and changes in practice (Carrington et al, 2010).


The format of the protocol should be: (Carrington et al, 2010)

  • Standardised and easily recognisable.
  • Clear and unambiguous.
  • Computer generated, not handwritten. Protocol templates stored electronically should be in read-only format to avoid unapproved alterations on the original. Access to the original protocol document should be restricted to authorised persons.
  • Clearly and fully referenced.
  • Authored, signed and dated with a review date, to allow everyone involved to identify and validate that they are using the most current version (Goldspiel et al, 2015).
  • Easily available to all staff. Web-based programs are useful in ensuring access to protocols for all staff including those outside the speciality or institution (e.g. emergency staff, GPs or patients). It must be ensured that the content is regularly maintained.
  • Clinical_question:What information should be included in a treatment protocol for cancer therapy?#Practice_point_1
  • The protocol should come from an evidence-based, published source or validated standard reference source such as the Australian government’s eviQ Cancer Treatments online resource (Cancer Institute NSW) or Children’s Oncology Group (COG) wherever possible. The use of an abstract, which does not represent full results/analysis, should be discouraged as a direct source for writing a chemotherapy order unless an exceptional case arises (Carrington et al, 2010).

There should be a formalised process of initial review by a multidisciplinary team before a protocol is implemented into clinical practice (Carrington et al, 2010). The responsibilities of each member of the team in verifying the content of a protocol should be clearly defined.


Protocols agreed within an institution should be incorporated into an electronic program (e.g. an oncology information system or computerised prescribing system). A fully validated electronic prescribing system should be utilised for the prescribing of chemotherapy wherever available (National Chemotherapy Advisory Group, 2009). Where an electronic system is not available pre-printed prescriptions should be used.


Investigational medications, doses and administration schedules must be verified against a study protocol that has been approved by all relevant regulatory agencies and study sponsors. Any protocol amendments should be distributed immediately and an up-to-date copy of the study protocol should be readily available for reference (Goldspiel et al, 2015).


Requirements associated with the delivery of the protocol at a local level should be considered including availability of supportive services (e.g. pathology and the ability to manage expected adverse effects or events) (Carrington et al, 2010).


Protocols should be reviewed on a regular basis for currency and changes in practice (Carrington et al, 2010).


The format of the protocol should be: (Carrington et al, 2010)

  • Standardised and easily recognisable.
  • Clear and unambiguous.
  • Computer generated, not handwritten. Protocol templates stored electronically should be in read-only format to avoid unapproved alterations on the original. Access to the original protocol document should be restricted to authorised persons.
  • Clearly and fully referenced.
  • Authored, signed and dated with a review date, to allow everyone involved to identify and validate that they are using the most current version (Goldspiel et al, 2015).
  • Easily available to all staff. Web-based programs are useful in ensuring access to protocols for all staff including those outside the speciality or institution (e.g. emergency staff, GPs or patients). It must be ensured that the content is regularly maintained.
  • Consensus based recommendation
Practice pointQuestion mark transparent.png

The use of out-of-date protocols can compromise patient safety. Superseded protocols should be archived (not deleted) and only be accessible to a limited number of senior staff. It is recognised that older protocols may be useful as a reference source or for educational purposes.


Facilities should consider convening a regular review meeting where current and proposed protocols can be discussed in a multidisciplinary format.


Variation from standard practice outlined within a treatment protocol including individual drug dose variations may be clinically appropriate for individual patients, and reasons for such variation and discussion with the patient and/or carer should be clearly documented. Monitoring and analysis of protocol and dose variations at an institutional level should be possible with local agreement on methods and frequency of auditing such variations being in place.


Key annual scientific meetings (e.g. American Society of Clinical Oncology, San Antonio Breast Symposium and The American Society of Hematology) often report on study data that may have practice changing implications for protocols. It is useful to convene a protocol review meeting after conferences to consider any major changes required.

  • Clinical_question:What information should be included in a treatment protocol for cancer therapy?#Practice_point_2
  • The use of out-of-date protocols can compromise patient safety. Superseded protocols should be archived (not deleted) and only be accessible to a limited number of senior staff. It is recognised that older protocols may be useful as a reference source or for educational purposes.

Facilities should consider convening a regular review meeting where current and proposed protocols can be discussed in a multidisciplinary format.


Variation from standard practice outlined within a treatment protocol including individual drug dose variations may be clinically appropriate for individual patients, and reasons for such variation and discussion with the patient and/or carer should be clearly documented. Monitoring and analysis of protocol and dose variations at an institutional level should be possible with local agreement on methods and frequency of auditing such variations being in place.


Key annual scientific meetings (e.g. American Society of Clinical Oncology, San Antonio Breast Symposium and The American Society of Hematology) often report on study data that may have practice changing implications for protocols. It is useful to convene a protocol review meeting after conferences to consider any major changes required.

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How is dosage of cancer therapy calculated for adults?

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Doses of cytotoxic chemotherapy should be dosed according to the actual body weight and/or BSA of the patient where there is a curative intent, unless a protocol specifies otherwise. Obesity alone should not be used as a rationale for capping BSA for chemotherapy dosing (Hunter et al, 2009; Griggs et al, 2012; Field et al, 2008).


Methods for calculating BSA should be standardised and the same method used by all clinicians at the institution. Many electronic programs (e.g. an oncology information system or computerised prescribing systems) allow the auto-calculation of BSA using the height and weight and for CrCl using the Cockcroft-Gault equation. Most available systems have configurable calculators embedded, thereby allowing each institution to select which formula they wish to use.


Special consideration should be given to calculating doses for individuals with poor performance status or those with co-morbidities which may affect tolerability and drug clearance. Dose capping or dose reductions made in this setting should be based on the individual patient parameters and clinical evidence (Gurney, 2002; Gurney, 2006). All doses that deviate from a standard evidence-based protocol should be clearly documented.


Specialised autologous or allogeneic transplant settings should adopt specific dosing policies related to the conditioning regimens used. Consensus guidelines are available (Bubalo et al, 2014).


Renal function should be used when calculating doses for renally excreted chemotherapy such as carboplatin. In obesity, actual body weight should be used in the calculation of CrCl via the Cockcroft-Gault method to obtain more reliable measures of renal function.


The re-weighing of the patient during therapy to recalculate the BSA and subsequent doses will depend on local policy, treatment intent and the extent of weight change. Dose adjustment should be made according to the presence or absence of toxicity, as well as changes in other factors that may affect medication elimination such as renal and hepatic function and concomitant medication. All dose reductions that deviate from a standard evidence-based protocol should be clearly documented. The checking of the patient's renal function during therapy with carboplatin to recalculate the carboplatin doses will depend on local policy, treatment intent and the extent of renal function change.

  • Clinical_question:How is dosage of cancer therapy calculated for adults?#Practice_point_1
  • Doses of cytotoxic chemotherapy should be dosed according to the actual body weight and/or BSA of the patient where there is a curative intent, unless a protocol specifies otherwise. Obesity alone should not be used as a rationale for capping BSA for chemotherapy dosing (Hunter et al, 2009; Griggs et al, 2012; Field et al, 2008).

Methods for calculating BSA should be standardised and the same method used by all clinicians at the institution. Many electronic programs (e.g. an oncology information system or computerised prescribing systems) allow the auto-calculation of BSA using the height and weight and for CrCl using the Cockcroft-Gault equation. Most available systems have configurable calculators embedded, thereby allowing each institution to select which formula they wish to use.


Special consideration should be given to calculating doses for individuals with poor performance status or those with co-morbidities which may affect tolerability and drug clearance. Dose capping or dose reductions made in this setting should be based on the individual patient parameters and clinical evidence (Gurney, 2002; Gurney, 2006). All doses that deviate from a standard evidence-based protocol should be clearly documented.


Specialised autologous or allogeneic transplant settings should adopt specific dosing policies related to the conditioning regimens used. Consensus guidelines are available (Bubalo et al, 2014).


Renal function should be used when calculating doses for renally excreted chemotherapy such as carboplatin. In obesity, actual body weight should be used in the calculation of CrCl via the Cockcroft-Gault method to obtain more reliable measures of renal function.


The re-weighing of the patient during therapy to recalculate the BSA and subsequent doses will depend on local policy, treatment intent and the extent of weight change. Dose adjustment should be made according to the presence or absence of toxicity, as well as changes in other factors that may affect medication elimination such as renal and hepatic function and concomitant medication. All dose reductions that deviate from a standard evidence-based protocol should be clearly documented. The checking of the patient's renal function during therapy with carboplatin to recalculate the carboplatin doses will depend on local policy, treatment intent and the extent of renal function change.

  • Consensus based recommendation
Practice pointQuestion mark transparent.png

The calculation for BSA should be standardised and the same method used by all clinicians at the institution. The use of printed tables and slide-rules for the calculation of BSA is an out-dated practice and should be avoided.


For carboplatin, if an estimated GFR based upon measured serum creatinine is used in the Calvert formula, consideration should be given to limit the maximal GFR for the calculation to 125 mL/min (U.S. Food and Drug Administration, 2015). This recommendation does not apply if the GFR is directly measured.


Where available, direct measurements of GFR using radiolabelled EDTA may be considered for patients receiving adjuvant or higher dose carboplatin.


Calculated doses may require ‘rounding’ to enable delivery of a measurable dose for both parenteral and oral doses and will depend on local practice (e.g. doxorubicin 53.85 mg could be rounded to 54 mg).


Dose adjustments should be made according to the presence or absence of toxicity, as well as changes in other factors that may affect medication elimination such as renal and hepatic function and concomitant medication. Dose adjustments are less commonly required with monoclonal antibodies.


Weight-based dosing is only used for a few cytotoxic chemotherapy agents including cladribine, melphalan and arsenic. This is largely based on how medicines were initially developed.


In the absence of data suggesting increased toxicity for underweight or obese individuals receiving weight-based dosing, doses should be based upon actual body weight.

  • Clinical_question:How is dosage of cancer therapy calculated for adults?#Practice_point_2
  • The calculation for BSA should be standardised and the same method used by all clinicians at the institution. The use of printed tables and slide-rules for the calculation of BSA is an out-dated practice and should be avoided.

For carboplatin, if an estimated GFR based upon measured serum creatinine is used in the Calvert formula, consideration should be given to limit the maximal GFR for the calculation to 125 mL/min (U.S. Food and Drug Administration, 2015). This recommendation does not apply if the GFR is directly measured.


Where available, direct measurements of GFR using radiolabelled EDTA may be considered for patients receiving adjuvant or higher dose carboplatin.


Calculated doses may require ‘rounding’ to enable delivery of a measurable dose for both parenteral and oral doses and will depend on local practice (e.g. doxorubicin 53.85 mg could be rounded to 54 mg).


Dose adjustments should be made according to the presence or absence of toxicity, as well as changes in other factors that may affect medication elimination such as renal and hepatic function and concomitant medication. Dose adjustments are less commonly required with monoclonal antibodies.


Weight-based dosing is only used for a few cytotoxic chemotherapy agents including cladribine, melphalan and arsenic. This is largely based on how medicines were initially developed.


In the absence of data suggesting increased toxicity for underweight or obese individuals receiving weight-based dosing, doses should be based upon actual body weight.

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How is dosage of cancer therapy calculated for paediatric patients?

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Patients who weigh more than 10kg should have cytotoxic chemotherapy dosed according to the BSA unless an approved protocol specifies otherwise. The Mosteller method is most commonly used (Mosteller, 1987).


Patients who weigh less than 10kg should have their cytotoxic chemotherapy dosed according to weight based calculations. The ‘rule of 30’ is used to adjust a chemotherapy dose from mg/m2 to mg/kg. This is where the mg/m2 dose is divided by 30 to get the mg/kg dose to administer (Ceja et al, 2013).


Paediatric patients should have their height and weight measured weekly when present in a health care facility and prior to the beginning of each cycle of treatment (Neuss et al, 2017; Belderson and Billett, 2017). Subsequent doses must be calculated on the new BSA or weight. If the dose has been prepared in advance with a previous height and weight, the dose administered must be within 5-10% of the dose according to the most recent height and weight.


Caution should be exercised when using a protocol where the study population did not include patients aged <1 year. Significant consideration of dose adjustments should be made by experienced clinicians before any doses are administered.

  • Clinical_question:How is dosage of cancer therapy calculated for paediatric patients?#Practice_point_1
  • Patients who weigh more than 10kg should have cytotoxic chemotherapy dosed according to

the BSA unless an approved protocol specifies otherwise. The Mosteller method is most commonly used (Mosteller, 1987).


Patients who weigh less than 10kg should have their cytotoxic chemotherapy dosed according to weight based calculations. The ‘rule of 30’ is used to adjust a chemotherapy dose from mg/m2 to mg/kg. This is where the mg/m2 dose is divided by 30 to get the mg/kg dose to administer (Ceja et al, 2013).


Paediatric patients should have their height and weight measured weekly when present in a health care facility and prior to the beginning of each cycle of treatment (Neuss et al, 2017; Belderson and Billett, 2017). Subsequent doses must be calculated on the new BSA or weight. If the dose has been prepared in advance with a previous height and weight, the dose administered must be within 5-10% of the dose according to the most recent height and weight.


Caution should be exercised when using a protocol where the study population did not include patients aged <1 year. Significant consideration of dose adjustments should be made by experienced clinicians before any doses are administered.

  • Consensus based recommendation
Practice pointQuestion mark transparent.png

Protocols vary in the age and weight cut-offs for weight based dosing in small children. Some protocols use age (e.g. <12 months or <3 years) whereas other protocols use weight (e.g. <10kg or <12kg) or BSA (e.g. <0.6m2). If a patient falls close to a category that may require a change in dose calculation there may be a significant increase in the calculated dose. It is recommended to closely review how the child has tolerated previous doses before giving the higher dose.


Protocols vary in how they cater for maturity of organ systems with respect to dosing of cytotoxic chemotherapy. Most protocols will have significant dose reductions for patients <6 months of age and modest dose reductions for patients between 6-12 months of age.


Carboplatin doses must be based on laboratory GFR results and not based on calculations using creatinine levels.


Renal function can be difficult to assess. GFR is the best indicator of renal function in children and adolescents. If a patient >1 year of age has a creatinine above that expected for their age, the Modified Schwartz formula should be used to estimate Creatinine Clearance (Schwartz and Work, 2009). Dose reductions or formal GFR measurement may be required.


Rounding of doses to allow safe measurement and administration is often required when tablets are the only available dosage form. This may mean the total weekly dosage is split over the week, potentially giving different doses on alternate days. The total weekly dose administered should be within 10% of the calculated dose based on the patient’s height and weight.

  • Clinical_question:How is dosage of cancer therapy calculated for paediatric patients?#Practice_point_2
  • Protocols vary in the age and weight cut-offs for weight based dosing in small children. Some protocols use age (e.g. <12 months or <3 years) whereas other protocols use weight (e.g. <10kg or <12kg) or BSA (e.g. <0.6m2). If a patient falls close to a category that may require a change in dose calculation there may be a significant increase in the calculated dose. It is recommended to closely review how the child has tolerated previous doses before giving the higher dose.

Protocols vary in how they cater for maturity of organ systems with respect to dosing of cytotoxic chemotherapy. Most protocols will have significant dose reductions for patients <6 months of age and modest dose reductions for patients between 6-12 months of age.


Carboplatin doses must be based on laboratory GFR results and not based on calculations using creatinine levels.


Renal function can be difficult to assess. GFR is the best indicator of renal function in children and adolescents. If a patient >1 year of age has a creatinine above that expected for their age, the Modified Schwartz formula should be used to estimate Creatinine Clearance (Schwartz and Work, 2009). Dose reductions or formal GFR measurement may be required.


Rounding of doses to allow safe measurement and administration is often required when tablets are the only available dosage form. This may mean the total weekly dosage is split over the week, potentially giving different doses on alternate days. The total weekly dose administered should be within 10% of the calculated dose based on the patient’s height and weight.

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What information should be provided to patients and carers about the cancer therapy?

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All patients should receive verbal and written information about their treatment, regardless of the treatment location. This should take place at a time when the patient and carer are able to listen and comprehend the information and ask questions about the treatment (Goldspiel et al, 2015). Information should be given on the first treatment visit and reinforced on subsequent visits. The type and content of information that has been provided and discussed with the patient should be recorded in the patient’s healthcare record.


The role the doctor, nurse and pharmacist have in providing education should be clearly defined within institutions, including who has primary responsibility for specific education tasks (Neuss et al, 2017; Goldspiel et al, 2015; Polovich et al, 2014). The legal and professional requirements of each discipline in the provision of patient information must be considered and patient education must be carried out by appropriately trained staff.


Patients receiving oral cancer therapy should be provided with additional information stated in Table 4 in accordance with the Society of Hospital Pharmacists of Australia (SHPA) Standards of Practice for the Pharmaceutical Care of Patients Receiving Oral Chemotherapy (The Society of Hospital Pharmacists of Australia Committee of Specialty Practice in Cancer Services, 2007) and with the American Society of Clinical Oncology (ASCO) and the Oncology Nursing Society (ONS) Chemotherapy Safety Standards (Neuss et al, 2017).


Consumer medication information leaflets (CMI’s) must be provided if available and appropriate, however the nature and the context in which cancer therapies are used often limits their availability or suitability. Guidance on how to use CMI’s may be found in the SHPA Standards of Practice for the Provision of Consumer Medicines Information by Pharmacists in Hospitals (The Society of Hospital Pharmacists of Australia Committee of Specialty Practice, 2007).


Information resources should be suitable to describe the treatment being provided and the patients’ health literacy level. Locally developed information sources should be reviewed and endorsed by a suitable committee that includes consumer input. Information on cancer treatment and protocols are available from established organisations such as eviQ Cancer Treatments Online (Cancer Institute NSW), the Cancer Council and community-based organisations (e.g. the Leukaemia Foundation). Some of these organisations also provide translated resources for people from culturally and linguistically diverse communities.


Patients requesting information about complementary therapies should receive adequate and unbiased information about complementary therapies and the potential impact that using complementary therapy may have on the treatment they are receiving and their disease. A number of resources are available to guide these discussions and support requests from patients for information (Cancer Council Australia, May 2015; Clinical Oncology Society of Australia, May 2013).

  • Clinical_question:What information should be provided to patients and carers about the cancer therapy?#Practice_point_1
  • All patients should receive verbal and written information about their treatment, regardless of the treatment location. This should take place at a time when the patient and carer are able to listen and comprehend the information and ask questions about the treatment (Goldspiel et al, 2015). Information should be given on the first treatment visit and reinforced on subsequent visits. The type and content of information that has been provided and discussed with the patient should be recorded in the patient’s healthcare record.

The role the doctor, nurse and pharmacist have in providing education should be clearly defined within institutions, including who has primary responsibility for specific education tasks (Neuss et al, 2017; Goldspiel et al, 2015; Polovich et al, 2014). The legal and professional requirements of each discipline in the provision of patient information must be considered and patient education must be carried out by appropriately trained staff.


Patients receiving oral cancer therapy should be provided with additional information stated in Table 4 in accordance with the Society of Hospital Pharmacists of Australia (SHPA) Standards of Practice for the Pharmaceutical Care of Patients Receiving Oral Chemotherapy (The Society of Hospital Pharmacists of Australia Committee of Specialty Practice in Cancer Services, 2007) and with the American Society of Clinical Oncology (ASCO) and the Oncology Nursing Society (ONS) Chemotherapy Safety Standards (Neuss et al, 2017).


Consumer medication information leaflets (CMI’s) must be provided if available and appropriate, however the nature and the context in which cancer therapies are used often limits their availability or suitability. Guidance on how to use CMI’s may be found in the SHPA Standards of Practice for the Provision of Consumer Medicines Information by Pharmacists in Hospitals (The Society of Hospital Pharmacists of Australia Committee of Specialty Practice, 2007).


Information resources should be suitable to describe the treatment being provided and the patients’ health literacy level. Locally developed information sources should be reviewed and endorsed by a suitable committee that includes consumer input. Information on cancer treatment and protocols are available from established organisations such as eviQ Cancer Treatments Online (Cancer Institute NSW), the Cancer Council and community-based organisations (e.g. the Leukaemia Foundation). Some of these organisations also provide translated resources for people from culturally and linguistically diverse communities.


Patients requesting information about complementary therapies should receive adequate and unbiased information about complementary therapies and the potential impact that using complementary therapy may have on the treatment they are receiving and their disease. A number of resources are available to guide these discussions and support requests from patients for information (Cancer Council Australia, May 2015; Clinical Oncology Society of Australia, May 2013).

  • Consensus based recommendation
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It is useful to provide patients with a list of websites appropriate for them to obtain further evidence-based information on their disease and treatment.


The provision of information should be coordinated across the disciplines to ensure the patient and/or carer receives information that is consistent, appropriate and relevant to their treatment. Education should include not only the patient but also the family, caregivers or any other persons who may be involved in the care and/or support of the patient (Neuss et al, 2017; Belderson and Billett, 2017; Goldspiel et al, 2015).


Written information in languages other than English should be provided if available. Appropriately trained interpreters should be used if required when providing education/information about treatment.


Medication lists, diaries and calendars can assist with patient adherence and the recording of any adverse effects.


Patients and caregivers can play a valuable role in error prevention in the administration checking process. Explaining the checking process and what is being administered while encouraging patients to let nursing staff know if they observe anything different from the routine administration process can help identify potential errors. This needs to be balanced by the patient’s willingness and capability to support this role and provide input (Schwappach and Wernli, 2010).

  • Clinical_question:What information should be provided to patients and carers about the cancer therapy?#Practice_point_2
  • It is useful to provide patients with a list of websites appropriate for them to obtain further evidence-based information on their disease and treatment.

The provision of information should be coordinated across the disciplines to ensure the patient and/or carer receives information that is consistent, appropriate and relevant to their treatment. Education should include not only the patient but also the family, caregivers or any other persons who may be involved in the care and/or support of the patient (Neuss et al, 2017; Belderson and Billett, 2017; Goldspiel et al, 2015).


Written information in languages other than English should be provided if available. Appropriately trained interpreters should be used if required when providing education/information about treatment.


Medication lists, diaries and calendars can assist with patient adherence and the recording of any adverse effects.


Patients and caregivers can play a valuable role in error prevention in the administration checking process. Explaining the checking process and what is being administered while encouraging patients to let nursing staff know if they observe anything different from the routine administration process can help identify potential errors. This needs to be balanced by the patient’s willingness and capability to support this role and provide input (Schwappach and Wernli, 2010).

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What additional safety practices should be followed when providing oral cancer therapy?

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Oral cancer therapies should be subject to the same standards for prescribing, verification, dispensing and administration as cancer therapies via other routes, with additional safeguards to support safe self-administration by patients and their caregivers in the home setting (Carrington, 2015; Carrington, 2013).


All healthcare professionals involved in prescribing, dispensing and administering oral cancer therapies need to be appropriately trained to assist patients and/or caregivers with issues pertaining to adherence, toxicity management and safety issues in the home setting (NHS National Patient Safety Agency UK, 2008; Taylor et al, 2006; Parsad and Ratain, 2007; Society of Hospital Pharmacists of Australia Committee of Specialty Practice in Cancer Services, 2007; Scottish Executive Health Department, 2005; Halfdanarson and Jatoi, 2010; Moore, 2010).

  • Clinical_question:What additional safety practices should be followed when providing oral cancer therapy?#Practice_point_1
  • Oral cancer therapies should be subject to the same standards for prescribing, verification, dispensing and administration as cancer therapies via other routes, with additional safeguards to support safe self-administration by patients and their caregivers in the home setting (Carrington, 2015; Carrington, 2013).

All healthcare professionals involved in prescribing, dispensing and administering oral cancer therapies need to be appropriately trained to assist patients and/or caregivers with issues pertaining to adherence, toxicity management and safety issues in the home setting (NHS National Patient Safety Agency UK, 2008; Taylor et al, 2006; Parsad and Ratain, 2007; Society of Hospital Pharmacists of Australia Committee of Specialty Practice in Cancer Services, 2007; Scottish Executive Health Department, 2005; Halfdanarson and Jatoi, 2010; Moore, 2010).

  • Consensus based recommendation
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Online resources such as eviQ (Cancer Institute NSW) are available to assist community pharmacists on safety issues around oral therapy. EviQ education online provides a useful resource on oral antineoplastic therapy (Cancer Institute NSW).


Institutions should consider implementing adequate support and education programs to facilitate patient understanding of how to take medication, when to take medication, what to look out for in terms of potential side effects and when to report problems (Winkeljohn, 2010; Halfdanarson and Jatoi, 2010; Neuss et al, 2017).

  • Clinical_question:What additional safety practices should be followed when providing oral cancer therapy?#Practice_point_2
  • Online resources such as eviQ (Cancer Institute NSW) are available to assist community pharmacists on safety issues around oral therapy. EviQ education online provides a useful resource on oral antineoplastic therapy (Cancer Institute NSW).

Institutions should consider implementing adequate support and education programs to facilitate patient understanding of how to take medication, when to take medication, what to look out for in terms of potential side effects and when to report problems (Winkeljohn, 2010; Halfdanarson and Jatoi, 2010; Neuss et al, 2017).

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What special considerations are required to minimise risk when providing cancer therapy to older adults?

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A comprehensive assessment using a specific tool should be performed prior to the initiation of systemic chemotherapy in the older person. Validated chemotherapy toxicity prediction tools such as the Cancer and Aging Research Group (CARG) toxicity tool (Cancer and Aging Research Group) and the Chemotherapy Risk Assessment Scale for High-Age Patients (CRASH) toxicity tool (Moffitt Cancer Center) are recommended (Hurria et al, 2011; Extermann et al, 2012).


A comprehensive medication history taken by a suitable healthcare professional (preferably a pharmacist) (Lichtman et al, 2014; Carrington et al, 2010) should be incorporated into the evaluation of the older cancer patient. Assessment of actual and potential medication interactions, medication-disease interactions, suitability of medication/rationalisation and opportunities for de-prescribing where clinically appropriate should occur.

  • Clinical_question:What special considerations are required to minimise risk when providing cancer therapy to older adults?#Practice_point_1
  • A comprehensive assessment using a specific tool should be performed prior to the initiation of systemic chemotherapy in the older person. Validated chemotherapy toxicity prediction tools such as the Cancer and Aging Research Group (CARG) toxicity tool (Cancer and Aging Research Group) and the Chemotherapy Risk Assessment Scale for High-Age Patients (CRASH) toxicity tool (Moffitt Cancer Center) are recommended (Hurria et al, 2011; Extermann et al, 2012).

A comprehensive medication history taken by a suitable healthcare professional (preferably a pharmacist) (Lichtman et al, 2014; Carrington et al, 2010) should be incorporated into the evaluation of the older cancer patient. Assessment of actual and potential medication interactions, medication-disease interactions, suitability of medication/rationalisation and opportunities for de-prescribing where clinically appropriate should occur.

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What special considerations are required to minimise risk when providing cancer therapy to paediatric patients?

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Children with cancer must be treated by a multidisciplinary team of staff trained and experienced in paediatric oncology to maximize optimal treatment outcomes and the safety of treatment with cancer medications and their associated toxicities.


Children with cancer should be offered the opportunity to participate in clinical trials when available. Continued clinical trials are vital to improving optimal treatment of children with cancer in the future.


Children with cancer should be treated with treatment protocols written specifically for paediatric patients by large cooperative groups wherever possible. For example: COG (National Cancer Institute - Children's Oncology Group) or the International BFM Study Group.

  • Clinical_question:What special considerations are required to minimise risk when providing cancer therapy to paediatric patients?#Practice_point_1
  • Children with cancer must be treated by a multidisciplinary team of staff trained and experienced in paediatric oncology to maximize optimal treatment outcomes and the safety of treatment with cancer medications and their associated toxicities.

Children with cancer should be offered the opportunity to participate in clinical trials when available. Continued clinical trials are vital to improving optimal treatment of children with cancer in the future.


Children with cancer should be treated with treatment protocols written specifically for paediatric patients by large cooperative groups wherever possible. For example: COG (National Cancer Institute - Children's Oncology Group) or the International BFM Study Group.

  • Consensus based recommendation
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Given the rarity of some paediatric tumour types, it is acknowledged that in some circumstances chemotherapy may need to be based on journal articles reporting on small clinical trials or case series or consensus-based specialist opinion.


Long term follow-up programs should be established to monitor for and manage the late toxicities of cancer therapies administered to children. These should address transition to adult services and the role of general practitioners.

  • Clinical_question:What special considerations are required to minimise risk when providing cancer therapy to paediatric patients?#Practice_point_2
  • Given the rarity of some paediatric tumour types, it is acknowledged that in some circumstances chemotherapy may need to be based on journal articles reporting on small clinical trials or case series or consensus-based specialist opinion.

Long term follow-up programs should be established to monitor for and manage the late toxicities of cancer therapies administered to children. These should address transition to adult services and the role of general practitioners.

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What special considerations are required for clinical trials or special access schemes for cancer therapy?

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Clinical trials


The management of the treatment within a clinical trial should be limited to those familiar with the trial protocol.


Clinical trial protocols should clearly outline the treatment protocol; however the format may differ according to the local ethics/governance requirements. Steps should be taken to ensure that information is presented in a clear manner in the clinical trial protocol through a multidisciplinary review process.


Medicine access programs


The recommendations of the Council of Australian Therapeutic Advisory Groups should be applied to the conduct of any MAP use in the context of cancer therapy (Council of Australian Therapeutic Advisory Groups, 2015). Responsibilities of all parties involved in the provision of the MAP should be documented.


Approval should be obtained from the local Drug and Therapeutics committee (or similar) to conduct the program and there must be a process of informed patient consent. Continued access to such medications may be limited by the agreement between the Pharmaceutical company and the treating team.


Detailed information on the use of the agent and its associated toxicities should be obtained from the pharmaceutical company that sponsors the scheme or an appropriate source (e.g. the principal investigator at a centre that participated in the trial).

  • Clinical_question:What special considerations are required for clinical trials or special access schemes for cancer therapy?#Practice_point_1
  • Clinical trials

The management of the treatment within a clinical trial should be limited to those familiar with the trial protocol.


Clinical trial protocols should clearly outline the treatment protocol; however the format may differ according to the local ethics/governance requirements. Steps should be taken to ensure that information is presented in a clear manner in the clinical trial protocol through a multidisciplinary review process.


Medicine access programs


The recommendations of the Council of Australian Therapeutic Advisory Groups should be applied to the conduct of any MAP use in the context of cancer therapy (Council of Australian Therapeutic Advisory Groups, 2015). Responsibilities of all parties involved in the provision of the MAP should be documented.


Approval should be obtained from the local Drug and Therapeutics committee (or similar) to conduct the program and there must be a process of informed patient consent. Continued access to such medications may be limited by the agreement between the Pharmaceutical company and the treating team.


Detailed information on the use of the agent and its associated toxicities should be obtained from the pharmaceutical company that sponsors the scheme or an appropriate source (e.g. the principal investigator at a centre that participated in the trial).

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What are the special safety considerations when providing intrathecal cancer therapy?

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All staff responsible for prescribing, dispensing and administering intrathecal chemotherapy should be aware of the catastrophic outcomes associated with the errors in administering incorrect chemotherapy medications via the intrathecal route.


All institutions where intrathecal chemotherapy is administered should have a procedure in place outlining the processes for prescribing, dispensing and administering intrathecal chemotherapy within that institution. This procedure must be developed with the involvement of all the relevant staff groups (medical, pharmacy and nursing staff) and must be approved by whichever body within the institution has delegated governance responsibility for approving medication policies or procedures.


All staff involved in prescribing, dispensing and administering intrathecal therapy should undergo appropriate training and be assessed as competent to perform their roles and responsibilities regarding intrathecal therapy.


A register of staff designated as competent to prescribe, prepare, dispense, supply, receive or administer intrathecal therapy for cancer should be maintained and accessible across the institution. Only staff listed on the register should undertake the specified tasks.

  • Clinical_question:What are the special safety considerations when providing intrathecal cancer therapy?#Practice_point_1
  • All staff responsible for prescribing, dispensing and administering intrathecal chemotherapy should be aware of the catastrophic outcomes associated with the errors in administering incorrect chemotherapy medications via the intrathecal route.

All institutions where intrathecal chemotherapy is administered should have a procedure in place outlining the processes for prescribing, dispensing and administering intrathecal chemotherapy within that institution. This procedure must be developed with the involvement of all the relevant staff groups (medical, pharmacy and nursing staff) and must be approved by whichever body within the institution has delegated governance responsibility for approving medication policies or procedures.


All staff involved in prescribing, dispensing and administering intrathecal therapy should undergo appropriate training and be assessed as competent to perform their roles and responsibilities regarding intrathecal therapy.


A register of staff designated as competent to prescribe, prepare, dispense, supply, receive or administer intrathecal therapy for cancer should be maintained and accessible across the institution. Only staff listed on the register should undertake the specified tasks.

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Which cancer medications are more prone to errors?

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Vinca alkaloids


All vinca alkaloids for administration to adult patients must be supplied in an infusion bag. The minimum recommended volume is 50 mL to be administered over 5–15 min. All vinca alkaloids for administration to paediatric patients over 10 years of age must be supplied in an infusion bag in a volume of 20–50 mL to be administered intravenously over 5–10 min. For patients younger than 10 years a risk assessment must be carried out to support any decision to use syringes instead of infusion bags.


Distinctive warning labels must be placed on all vinca alkaloids preparations, “FOR INTRAVENOUS USE ONLY. FATAL IF ADMINISTERED BY ANY OTHER ROUTE”.


Etoposide


All etoposide phosphate preparations should be prescribed and labelled as the number of milligrams of etoposide base required as follows: Etoposide (as [the] PHOSPHATE) x mg. Where x is the number of milligrams of etoposide base.


Electronic prescribing and management systems must ensure any automated calculations are based on the correct formulation of etoposide and clearly identify this to prescribers, pharmacists and nursing staff.

  • Clinical_question:Which cancer medications are more prone to errors?#Practice_point_1
  • Vinca alkaloids

All vinca alkaloids for administration to adult patients must be supplied in an infusion bag. The minimum recommended volume is 50 mL to be administered over 5–15 min. All vinca alkaloids for administration to paediatric patients over 10 years of age must be supplied in an infusion bag in a volume of 20–50 mL to be administered intravenously over 5–10 min. For patients younger than 10 years a risk assessment must be carried out to support any decision to use syringes instead of infusion bags.


Distinctive warning labels must be placed on all vinca alkaloids preparations, “FOR INTRAVENOUS USE ONLY. FATAL IF ADMINISTERED BY ANY OTHER ROUTE”.


Etoposide


All etoposide phosphate preparations should be prescribed and labelled as the number of milligrams of etoposide base required as follows: Etoposide (as [the] PHOSPHATE) x mg. Where x is the number of milligrams of etoposide base.


Electronic prescribing and management systems must ensure any automated calculations are based on the correct formulation of etoposide and clearly identify this to prescribers, pharmacists and nursing staff.

  • Consensus based recommendation
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Fatalities have occurred as a result of the inadvertent administration of bortezomib intrathecally. As bortezomib is always presented in a syringe for intravenous or subcutaneous use due to stability and administration requirements, precautions should be taken to reduce the risk of wrong route of administration. This includes labelling the final manufactured product prepared for administration with the words "For Intravenous or Subcutaneous Use Only - Fatal if Given by Other Routes" (Gilbar and Seger, 2013).


Facilities should consider internal education and the use of high risk alerts for cancer agents used locally that may cause dose or formulation confusion. For example:

  • Eribulin can be described by both the eribulin base and the mesylate formulation.
  • Trastuzumab EMTANSINE (conjugated MAB) can be confused with trastuzumab (MAB).
  • NAB paclitaxel (nano bound albumin formulation) can be confused with paclitaxel.
  • Rituximab and trastuzumab are now available to be administered via the subcutaneous and intravenous route. Different formulation and dosing schedules exist for these 2 medications according to route of administration.
  • Clinical_question:Which cancer medications are more prone to errors?#Practice_point_2
  • Fatalities have occurred as a result of the inadvertent administration of bortezomib intrathecally. As bortezomib is always presented in a syringe for intravenous or subcutaneous use due to stability and administration requirements, precautions should be taken to reduce the risk of wrong route of administration. This includes labelling the final manufactured product prepared for administration with the words "For Intravenous or Subcutaneous Use Only - Fatal if Given by Other Routes" (Gilbar and Seger, 2013).

Facilities should consider internal education and the use of high risk alerts for cancer agents used locally that may cause dose or formulation confusion. For example:

  • Eribulin can be described by both the eribulin base and the mesylate formulation.
  • Trastuzumab EMTANSINE (conjugated MAB) can be confused with trastuzumab (MAB).
  • NAB paclitaxel (nano bound albumin formulation) can be confused with paclitaxel.
  • Rituximab and trastuzumab are now available to be administered via the subcutaneous and intravenous route. Different formulation and dosing schedules exist for these 2 medications according to route of administration.
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Can the use of complementary and integrative medicines affect the safety of cancer therapy?

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Any use of CAM should be assessed for safety against the patient’s cancer treatment protocol. All CAM should be considered in terms of any potential to interact with the patient’s therapy, thereby causing either an increased risk of toxicity or reduced efficacy of the planned therapy. All CAM use should be recorded in the patient’s health care record.

  • Clinical_question:Can the use of complementary and integrative medicines affect the safety of cancer therapy?#Practice_point_1
  • Any use of CAM should be assessed for safety against the patient’s cancer treatment protocol. All CAM should be considered in terms of any potential to interact with the patient’s therapy, thereby causing either an increased risk of toxicity or reduced efficacy of the planned therapy. All CAM use should be recorded in the patient’s health care record.
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What factors should be taken into account when using electronic systems to support the delivery of cancer therapy?

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Electronic prescribing and information management system specifications should ensure that all recommendations made within these guidelines with respect to the safe prescribing, dispensing and administration of cancer therapy are met. An electronic prescribing and information management system should be implemented in all institutions where cancer therapy is prescribed and ordered for adult and paediatric patients.


Implementation of an electronic prescribing and information management system should be overseen by an institutional governance process and facilities should seek full vendor engagement in implementing improvements to the system.


The implementation and operation of an electronic prescribing and information management system should include consideration of the British Oncology Pharmacy Association (BOPA) and Australian Commission on Safety and Quality in Health Care (ACSQHC) guidelines.

  • Clinical_question:What factors should be taken into account when using electronic systems to support the delivery of cancer therapy?#Practice_point_1
  • Electronic prescribing and information management system specifications should ensure that all recommendations made within these guidelines with respect to the safe prescribing, dispensing and administration of cancer therapy are met. An electronic prescribing and information management system should be implemented in all institutions where cancer therapy is prescribed and ordered for adult and paediatric patients.

Implementation of an electronic prescribing and information management system should be overseen by an institutional governance process and facilities should seek full vendor engagement in implementing improvements to the system.


The implementation and operation of an electronic prescribing and information management system should include consideration of the British Oncology Pharmacy Association (BOPA) and Australian Commission on Safety and Quality in Health Care (ACSQHC) guidelines.

  • Consensus based recommendation
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Training: All staff operating e-prescribing systems must be appropriately trained and competent to perform their specific roles.


Set-up and Protocol Development: e-prescribing systems must allow stringent controlled user access for approved staff to set-up chemotherapy protocols and allow a way to build protocols and keep them in an inactivated state until appropriate quality assurance processes have occurred to enable activation and access by prescribers.

  • Chemotherapy protocols should incorporate the recommendations outlined in these guidelines including nomenclature, dosing, schedule, diagnosis and testing and allow incorporation of appropriate supportive care regimens.

Validation: Independent checking of the system once set-up is complete and for each individual chemotherapy protocol once built should be carried out by an experienced clinical cancer pharmacist, a consultant oncologist or haematologist and an experienced chemotherapy nurse specialist as appropriate and defined locally.


Prescribing: Security access enabling personnel to prescribe chemotherapy in line with the prescribing section of these guidelines must only be granted to locally approved prescribers. Appropriate clinical decision support and prescribing alerts (including but not limited to allergies, medication interactions, maximum or cumulative dose breaches, wrong route of administration, etc) must also be incorporated into the system.


Verification: Security access enabling personnel to verify chemotherapy medication orders on e-prescribing systems in line with the dispensing section of these guidelines must only be granted to locally approved cancer pharmacists.


Administration: Where e-prescribing systems allow electronic recording of administration, security access enabling personnel to record the administration of chemotherapy on e-prescribing systems must only be granted to approved staff who have been trained to administer chemotherapy.


Security: Levels of access must be determined locally and applied to different staff groups and/or individuals according to their professional roles and responsibilities after undertaking appropriate training (as outlined under the competency and skills sections of these guidelines related to prescribing, dispensing and administration).


Monitoring: Appropriate ongoing monitoring of e-prescribing system performance including errors and near-misses in line with the local institution’s practices must be recorded and actioned where appropriate to ensure continuous system improvement occurs and to highlight areas of risks being inadvertently introduced into practice.


System Governance and Policies: Procedures for system set-up and use, scheduled and unplanned downtime and disaster recovery must be developed and maintained.

  • Clinical_question:What factors should be taken into account when using electronic systems to support the delivery of cancer therapy?#Practice_point_2
  • Training: All staff operating e-prescribing systems must be appropriately trained and competent to perform their specific roles.

Set-up and Protocol Development: e-prescribing systems must allow stringent controlled user access for approved staff to set-up chemotherapy protocols and allow a way to build protocols and keep them in an inactivated state until appropriate quality assurance processes have occurred to enable activation and access by prescribers.

  • Chemotherapy protocols should incorporate the recommendations outlined in these guidelines including nomenclature, dosing, schedule, diagnosis and testing and allow incorporation of appropriate supportive care regimens.

Validation: Independent checking of the system once set-up is complete and for each individual chemotherapy protocol once built should be carried out by an experienced clinical cancer pharmacist, a consultant oncologist or haematologist and an experienced chemotherapy nurse specialist as appropriate and defined locally.


Prescribing: Security access enabling personnel to prescribe chemotherapy in line with the prescribing section of these guidelines must only be granted to locally approved prescribers. Appropriate clinical decision support and prescribing alerts (including but not limited to allergies, medication interactions, maximum or cumulative dose breaches, wrong route of administration, etc) must also be incorporated into the system.


Verification: Security access enabling personnel to verify chemotherapy medication orders on e-prescribing systems in line with the dispensing section of these guidelines must only be granted to locally approved cancer pharmacists.


Administration: Where e-prescribing systems allow electronic recording of administration, security access enabling personnel to record the administration of chemotherapy on e-prescribing systems must only be granted to approved staff who have been trained to administer chemotherapy.


Security: Levels of access must be determined locally and applied to different staff groups and/or individuals according to their professional roles and responsibilities after undertaking appropriate training (as outlined under the competency and skills sections of these guidelines related to prescribing, dispensing and administration).


Monitoring: Appropriate ongoing monitoring of e-prescribing system performance including errors and near-misses in line with the local institution’s practices must be recorded and actioned where appropriate to ensure continuous system improvement occurs and to highlight areas of risks being inadvertently introduced into practice.


System Governance and Policies: Procedures for system set-up and use, scheduled and unplanned downtime and disaster recovery must be developed and maintained.

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How can risk assessment and quality assurance activities minimise errors in cancer therapy?

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A governance body or appointed subcommittee consisting of all disciplines involved in the treatment process for cancer should be established. The governance body or committee should put into place systems for managing risk and processes for quality assurance including the conduct of regular audits.


A system should be in place for reporting adverse events, incidents and near misses (Womer et al, 2002). The “Root, Cause, Analysis” process should be undertaken for sentinel events. Where a near miss could have resulted in a serious adverse outcome it is recommended that a facility undertake a “Failure Mode Effectiveness Analysis” (Leape et al, 1995). A multidisciplinary review of process measures (such as rate and type of incidents and near misses) and outcome measures (such as chemotherapy related adverse events and unplanned admission or readmission rates) should be undertaken regularly to identify “error prone” areas that require remediation or treatment protocols whose use should be re-evaluated.

  • Clinical_question:How can risk assessment and quality assurance activities minimise errors in cancer therapy?#Practice_point_1
  • A governance body or appointed subcommittee consisting of all disciplines involved in the treatment process for cancer should be established. The governance body or committee should put into place systems for managing risk and processes for quality assurance including the conduct of regular audits.

A system should be in place for reporting adverse events, incidents and near misses (Womer et al, 2002). The “Root, Cause, Analysis” process should be undertaken for sentinel events. Where a near miss could have resulted in a serious adverse outcome it is recommended that a facility undertake a “Failure Mode Effectiveness Analysis” (Leape et al, 1995). A multidisciplinary review of process measures (such as rate and type of incidents and near misses) and outcome measures (such as chemotherapy related adverse events and unplanned admission or readmission rates) should be undertaken regularly to identify “error prone” areas that require remediation or treatment protocols whose use should be re-evaluated.

  • Consensus based recommendation
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The committee responsible for medication safety and quality assurance of cancer therapy should have representation on a hospital wide safety committee. This provides a useful forum for peer discussion, education and resolutions on safety issues that affect the patient population of the facility.


In the case of electronic prescribing systems, processes should be in place to regularly ensure the appropriate functioning of the system and decision support functions.

  • Clinical_question:How can risk assessment and quality assurance activities minimise errors in cancer therapy?#Practice_point_2
  • The committee responsible for medication safety and quality assurance of cancer therapy should have representation on a hospital wide safety committee. This provides a useful forum for peer discussion, education and resolutions on safety issues that affect the patient population of the facility.

In the case of electronic prescribing systems, processes should be in place to regularly ensure the appropriate functioning of the system and decision support functions.

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What occupational health and safety precautions should be followed when providing cancer therapy?

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Healthcare professionals should refer to state based documents for detailed requirements for safe handling of cytotoxic and related cancer therapies. The eviQ resource document "Safe Handling and Waste Management of Hazardous Drugs" should be used as a reference document in the absence of local guidance (Cancer Institute NSW).

  • Clinical_question:What occupational health and safety precautions should be followed when providing cancer therapy?#Practice_point_1
  • Healthcare professionals should refer to state based documents for detailed requirements for safe handling of cytotoxic and related cancer therapies. The eviQ resource document "Safe Handling and Waste Management of Hazardous Drugs" should be used as a reference document in the absence of local guidance (Cancer Institute NSW).
  • Consensus based recommendation
Practice pointQuestion mark transparent.png

Organisations must keep up-to-date with current information and practices in relation to occupational health and safety precautions for chemotherapy and targeted therapies and implement appropriate control measures.


All staff expected to handle hazardous substances and related waste are to have equitable access to training.


All staff expected to wear Personal Protective Equipment (PPE) to handle hazardous substances and related waste are to have training in the PPE processes, including gowning and disposal.


Staff should have access to current, evidence-based best practice resources to guide practice in relation to occupational health and safety.


Organisations must develop clear, unambiguous local policies and procedures related to the handling of chemotherapy, monoclonal antibodies, targeted therapies and related waste to protect the worker, the patient and the environment.


New therapies for cancer are continuously introduced into clinical practice. A process must be place to ensure occupational health and safety precautions are implemented that reflect exposure risks associated with mode of action and adverse effects.

  • Clinical_question:What occupational health and safety precautions should be followed when providing cancer therapy?#Practice_point_2
  • Organisations must keep up-to-date with current information and practices in relation to occupational health and safety precautions for chemotherapy and targeted therapies and implement appropriate control measures.

All staff expected to handle hazardous substances and related waste are to have equitable access to training.


All staff expected to wear Personal Protective Equipment (PPE) to handle hazardous substances and related waste are to have training in the PPE processes, including gowning and disposal.


Staff should have access to current, evidence-based best practice resources to guide practice in relation to occupational health and safety.


Organisations must develop clear, unambiguous local policies and procedures related to the handling of chemotherapy, monoclonal antibodies, targeted therapies and related waste to protect the worker, the patient and the environment.


New therapies for cancer are continuously introduced into clinical practice. A process must be place to ensure occupational health and safety precautions are implemented that reflect exposure risks associated with mode of action and adverse effects.

  • Good practice point

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Role of the Prescriber

What are the responsibilities of the Prescriber when prescribing cancer therapy and associated medications?

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The prescriber is responsible for: (Neuss et al, 2017; Belderson and Billett, 2017; Goldspiel et al, 2015; Carrington et al, 2010)

  • Making treatment decisions and ensuring that each treatment is appropriate for the patient according to diagnosis, laboratory parameters, performance status, organ function and any other relevant characteristics of the patient or their malignancy (e.g. genotype, tumour markers).
  • Ensuring that patients and/or their caregivers are adequately informed about their diagnosis and treatment and give consent for therapy. Where age-appropriate, assent of paediatric patients should also be obtained.
  • Monitoring the effects of treatment and ensuring that appropriate medical review of patients and laboratory results is performed during and after treatment.
  • Ensuring that all professional and legal responsibilities are met with respect to prescribing. This includes participating in the prescribing process as a team member with those involved in the dispensing and administration of the therapy.
  • Clinical_question:What are the responsibilities of the Prescriber when prescribing cancer therapy and associated medications?#Practice_point_1
  • The prescriber is responsible for: (Neuss et al, 2017; Belderson and Billett, 2017; Goldspiel et al, 2015; Carrington et al, 2010)
  • Making treatment decisions and ensuring that each treatment is appropriate for the patient according to diagnosis, laboratory parameters, performance status, organ function and any other relevant characteristics of the patient or their malignancy (e.g. genotype, tumour markers).
  • Ensuring that patients and/or their caregivers are adequately informed about their diagnosis and treatment and give consent for therapy. Where age-appropriate, assent of paediatric patients should also be obtained.
  • Monitoring the effects of treatment and ensuring that appropriate medical review of patients and laboratory results is performed during and after treatment.
  • Ensuring that all professional and legal responsibilities are met with respect to prescribing. This includes participating in the prescribing process as a team member with those involved in the dispensing and administration of the therapy.
  • Consensus based recommendation

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What competencies and skills are required when prescribing cancer therapy?

Consensus-based recommendationQuestion mark transparent.png

Chemotherapy and targeted therapies must only be prescribed by clinicians with appropriate skills, training and qualifications in the management of cancer.


General practitioners should only prescribe cancer chemotherapy and targeted therapies under the supervision of a medical oncologist or haematologist.

  • Clinical_question:What competencies and skills are required when prescribing cancer therapy?#Practice_point_1
  • Chemotherapy and targeted therapies must only be prescribed by clinicians with appropriate skills, training and qualifications in the management of cancer.

General practitioners should only prescribe cancer chemotherapy and targeted therapies under the supervision of a medical oncologist or haematologist.

  • Consensus based recommendation
Practice pointQuestion mark transparent.png

Local accreditation processes and descriptions of scope of practice should be considered for clinicians prescribing cancer therapy and related treatment.


Prescribing should take place in the context of a management plan devised by the patient’s treating clinician and where applicable, in conjunction with the multidisciplinary team.

  • Clinical_question:What competencies and skills are required when prescribing cancer therapy?#Practice_point_2
  • Local accreditation processes and descriptions of scope of practice should be considered for clinicians prescribing cancer therapy and related treatment.

Prescribing should take place in the context of a management plan devised by the patient’s treating clinician and where applicable, in conjunction with the multidisciplinary team.

  • Good practice point

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What is best practice for documenting and communicating the treatment plan?

Consensus-based recommendationQuestion mark transparent.png

A treatment plan must be completed for all patients receiving cancer therapy by the clinician initiating treatment and be available in a patient’s healthcare record at all times.


The treatment plan should follow a standard template and ideally be in a computer-generated format to ensure all required information is included.


The patient’s overall treatment plan should be discussed in a multidisciplinary meeting and should reflect other decisions made such as surgery and radiation therapy and requirements for nursing and allied health services. Where an MDT is not in existence within an institution, it is recommended that clinicians link into a centre that does hold such meetings.


Deviations from accepted protocols and dosing schedules must be documented in the plan and include clinical justification for the deviation or alteration. Published references supporting a deviation or change to the original protocol must be citied where applicable.


The treatment plan should be made available to the patient in a ‘patient friendly’ format to support shared decision making and ensure all healthcare providers that care for the patient have access to the overall plan for cancer treatment.


Where the treatment plan changes during treatment (e.g. if the patient is commenced on a new protocol or the dose changes) this should be clearly documented on the treatment plan, including the clinical justification (Goldspiel et al, 2015).

  • Clinical_question:What is best practice for documenting and communicating the treatment plan?#Practice_point_1
  • A treatment plan must be completed for all patients receiving cancer therapy by the clinician initiating treatment and be available in a patient’s healthcare record at all times.

The treatment plan should follow a standard template and ideally be in a computer-generated format to ensure all required information is included.


The patient’s overall treatment plan should be discussed in a multidisciplinary meeting and should reflect other decisions made such as surgery and radiation therapy and requirements for nursing and allied health services. Where an MDT is not in existence within an institution, it is recommended that clinicians link into a centre that does hold such meetings.


Deviations from accepted protocols and dosing schedules must be documented in the plan and include clinical justification for the deviation or alteration. Published references supporting a deviation or change to the original protocol must be citied where applicable.


The treatment plan should be made available to the patient in a ‘patient friendly’ format to support shared decision making and ensure all healthcare providers that care for the patient have access to the overall plan for cancer treatment.


Where the treatment plan changes during treatment (e.g. if the patient is commenced on a new protocol or the dose changes) this should be clearly documented on the treatment plan, including the clinical justification (Goldspiel et al, 2015).

  • Consensus based recommendation
Practice pointQuestion mark transparent.png

The treatment plan should include relevant background medical conditions, medications and adverse reactions to medications (Goldspiel et al, 2015) and a schedule of follow-up clinical visits and investigations (e.g. expected blood tests, three-monthly transthoracic echocardiogram with anti-Her2 agents).


The treatment plan should include necessary baseline assessments such as imaging, laboratory and functional investigations tailored to the patient and the proposed treatment (e.g. transthoracic echocardiogram to assess cardiac structure and function prior to potentially cardiotoxic agents such as anthracyclines or trastuzumab, or respiratory function testing prior to bleomycin). Other baseline interventions should also be documented, for example, fertility preservation such as sperm banking.


The American Society for Clinical Oncology (ASCO) Institute for Quality provides useful cancer treatment plan templates (ASCO Institute for Quality).

  • Clinical_question:What is best practice for documenting and communicating the treatment plan?#Practice_point_2
  • The treatment plan should include relevant background medical conditions, medications and adverse reactions to medications (Goldspiel et al, 2015) and a schedule of follow-up clinical visits and investigations (e.g. expected blood tests, three-monthly transthoracic echocardiogram with anti-Her2 agents).

The treatment plan should include necessary baseline assessments such as imaging, laboratory and functional investigations tailored to the patient and the proposed treatment (e.g. transthoracic echocardiogram to assess cardiac structure and function prior to potentially cardiotoxic agents such as anthracyclines or trastuzumab, or respiratory function testing prior to bleomycin). Other baseline interventions should also be documented, for example, fertility preservation such as sperm banking.


The American Society for Clinical Oncology (ASCO) Institute for Quality provides useful cancer treatment plan templates (ASCO Institute for Quality).

  • Good practice point

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How should information be presented in the medication order to minimise errors?

Consensus-based recommendationQuestion mark transparent.png

The following guidance is in addition to the legislative requirements of State/Territory Health regulations (Drugs and Poisons). (Carrington et al, 2010b; Goldspiel et al, 2015a)

  • The medication chart should be designed specifically for the purpose of prescribing chemotherapy, targeted therapy and supportive medication.
  • All known medication allergies must be recorded on the order and if no allergies are reported by the patient then ‘nil known allergies’ should be recorded.
  • The chemotherapy chart should be used to prescribe all parenteral and oral medications used in the treatment of cancer and should be approved by the facilities Drug & Therapeutics committee (or equivalent) and medical records/forms committee.
  • Sufficient space should be available to allow a clear description of the medication, date and time of administration, the dose, route and frequency without unnecessary abbreviations.
  • Sufficient space should be available to allow the signatures of the prescriber, pharmacist and nurse.
  • Prescribers should avoid the use of handwritten prescriptions (medication AND doses) with the use of pre-printed or computer generated orders being preferable. Where handwritten orders are unavoidable the order should be PRINTED using permanent black ink.
  • Verbal orders for the initiation of cancer therapy should not be permitted under any circumstance.
  • Where a copy of a chemotherapy order is to be sent to an offsite location it should be scanned not faxed. Faxing produces a poor copy of the original and can result in errors where lines obscure decimal points or where dosage details appear incomplete. Carbon copies should not be used.
  • A PBS script alone should not be used to prescribe chemotherapy by any route as it has insufficient space to provide the information required to ensure safe dispensing. An order written on an appropriate chemotherapy order chart should accompany a PBS script.

Physical and staffing resources should enable the prescriber to complete an order away from distractions and interruptions to maximise safety.

  • Clinical_question:How should information be presented in the medication order to minimise errors?#Practice_point_1
  • The following guidance is in addition to the legislative requirements of State/Territory Health regulations (Drugs and Poisons). (Carrington et al, 2010b; Goldspiel et al, 2015a)
  • The medication chart should be designed specifically for the purpose of prescribing chemotherapy, targeted therapy and supportive medication.
  • All known medication allergies must be recorded on the order and if no allergies are reported by the patient then ‘nil known allergies’ should be recorded.
  • The chemotherapy chart should be used to prescribe all parenteral and oral medications used in the treatment of cancer and should be approved by the facilities Drug & Therapeutics committee (or equivalent) and medical records/forms committee.
  • Sufficient space should be available to allow a clear description of the medication, date and time of administration, the dose, route and frequency without unnecessary abbreviations.
  • Sufficient space should be available to allow the signatures of the prescriber, pharmacist and nurse.
  • Prescribers should avoid the use of handwritten prescriptions (medication AND doses) with the use of pre-printed or computer generated orders being preferable. Where handwritten orders are unavoidable the order should be PRINTED using permanent black ink.
  • Verbal orders for the initiation of cancer therapy should not be permitted under any circumstance.
  • Where a copy of a chemotherapy order is to be sent to an offsite location it should be scanned not faxed. Faxing produces a poor copy of the original and can result in errors where lines obscure decimal points or where dosage details appear incomplete. Carbon copies should not be used.
  • A PBS script alone should not be used to prescribe chemotherapy by any route as it has insufficient space to provide the information required to ensure safe dispensing. An order written on an appropriate chemotherapy order chart should accompany a PBS script.

Physical and staffing resources should enable the prescriber to complete an order away from distractions and interruptions to maximise safety.

  • Consensus based recommendation
Practice pointQuestion mark transparent.png

Some electronic prescribing programs may use abbreviations that are not considered best practice (Australian Commission on Safety and Quality in Health Care, 2011a; Australian Commission on Safety and Quality in Health Care, 2011b). This should be taken into account when choosing and implementing electronic programs.

  • Clinical_question:How should information be presented in the medication order to minimise errors?#Practice_point_2
  • Some electronic prescribing programs may use abbreviations that are not considered best practice (Australian Commission on Safety and Quality in Health Care, 2011a; Australian Commission on Safety and Quality in Health Care, 2011b). This should be taken into account when choosing and implementing electronic programs.
  • Good practice point

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What is best practice when prescribing oral cancer treatment (chemotherapy and targeted therapy)?

Consensus-based recommendationQuestion mark transparent.png

Oral chemotherapy and targeted therapy should be written to the same standards as parenteral therapy.


Dose changes to oral chemotherapy regimens which are communicated directly to patients and/or caregivers must also be documented on a prescription, medication order and/or the patient’s medical record (Neuss et al, 2017; Belderson and Billett, 2017).


Oral chemotherapy and targeted therapy should only be prescribed by clinicians with appropriate skills and qualifications in the management and treatment of cancer. GPs should not prescribe oral therapy unless directed by the patient’s oncologist or haematologist.


Careful evaluation for potential interactions between the oral cancer medication and other prescribed medicines, complementary medicines and food should be carried out prior to prescribing oral therapy (Carrington, 2013; Carrington, 2015; Thakerar et al, 2014).

  • Clinical_question:What is best practice when prescribing oral cancer treatment (chemotherapy and targeted therapy)?#Practice_point_1
  • Oral chemotherapy and targeted therapy should be written to the same standards as parenteral therapy.

Dose changes to oral chemotherapy regimens which are communicated directly to patients and/or caregivers must also be documented on a prescription, medication order and/or the patient’s medical record (Neuss et al, 2017; Belderson and Billett, 2017).


Oral chemotherapy and targeted therapy should only be prescribed by clinicians with appropriate skills and qualifications in the management and treatment of cancer. GPs should not prescribe oral therapy unless directed by the patient’s oncologist or haematologist.


Careful evaluation for potential interactions between the oral cancer medication and other prescribed medicines, complementary medicines and food should be carried out prior to prescribing oral therapy (Carrington, 2013; Carrington, 2015; Thakerar et al, 2014).

  • Consensus based recommendation

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What is best practice when prescribing intrathecal therapy?

Consensus-based recommendationQuestion mark transparent.png

Institutions where prescribing of intrathecal chemotherapy occurs must be aware of the risks and are recommended to take steps as outlined below and elsewhere in these guidelines to minimise the chances of error as far as practicable.


Medical staff that prescribe and administer intrathecal therapy must receive education and training with respect to the prescribing and administration of intrathecal therapy. Clinicians must be assessed as competent to prescribe and administer.


Prescriptions for intrathecal therapy must specify the route of administration as “INTRATHECAL” written in full, in capitals and in bold for computer generated proformas. The abbreviation “IT” is NOT acceptable.


Where practical, intrathecal injections should be scheduled to be administered on a day that no other parenteral chemotherapy is being administered to the patient and given in an area where no other cytotoxic chemotherapy, biological therapy or targeted therapy is accessible (Gilbar, 2014).

  • Clinical_question:What is best practice when prescribing intrathecal therapy?#Practice_point_1
  • Institutions where prescribing of intrathecal chemotherapy occurs must be aware of the risks and are recommended to take steps as outlined below and elsewhere in these guidelines to minimise the chances of error as far as practicable.

Medical staff that prescribe and administer intrathecal therapy must receive education and training with respect to the prescribing and administration of intrathecal therapy. Clinicians must be assessed as competent to prescribe and administer.


Prescriptions for intrathecal therapy must specify the route of administration as “INTRATHECAL” written in full, in capitals and in bold for computer generated proformas. The abbreviation “IT” is NOT acceptable.


Where practical, intrathecal injections should be scheduled to be administered on a day that no other parenteral chemotherapy is being administered to the patient and given in an area where no other cytotoxic chemotherapy, biological therapy or targeted therapy is accessible (Gilbar, 2014).

  • Consensus based recommendation

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Role of the Pharmacist

What are the responsibilities of the Pharmacist when dispensing and supplying cancer therapy?

Consensus-based recommendationQuestion mark transparent.png

The pharmacist is responsible for ensuring:

  • The clinical verification of the treatment prescription/order including chemotherapy (both parenteral and oral) and supportive medications is performed according to the protocol, the patient’s treatment plan and patient parameters.
  • The treatment protocol used has been through the multidisciplinary review and approval processes.
  • The cancer therapy is prescribed on a designated medication chart specifically designed for prescribing the cancer therapy.
  • Identified discrepancies in the prescription/order of the cancer treatment are clarified and resolved.
  • An up-to-date treatment history relating to all chemotherapy medications, doses and treatment dates is available in the patients’ healthcare record.
  • The accurate dispensing of both parenteral and oral cancer therapy and related treatment including supportive care therapies.
  • All components of the prescription are supplied in a timely and safe manner.
  • The preparation of parenteral cytotoxics is carried out using premises and equipment suitable for aseptic manipulation of the product according to risk and standards of practice.
  • The appropriate health and safety standards are applied when handling hazardous oral medications such as oral cytotoxics.
  • All professional and legal responsibilities are met with respect to dispensing of medication.
  • All materials used for patient education are comprehensive, suitable for the patient’s treatment and routinely updated.
  • Clinical_question:What are the responsibilities of the Pharmacist when dispensing and supplying cancer therapy?#Practice_point_1
  • The pharmacist is responsible for ensuring:
  • The clinical verification of the treatment prescription/order including chemotherapy (both parenteral and oral) and supportive medications is performed according to the protocol, the patient’s treatment plan and patient parameters.
  • The treatment protocol used has been through the multidisciplinary review and approval processes.
  • The cancer therapy is prescribed on a designated medication chart specifically designed for prescribing the cancer therapy.
  • Identified discrepancies in the prescription/order of the cancer treatment are clarified and resolved.
  • An up-to-date treatment history relating to all chemotherapy medications, doses and treatment dates is available in the patients’ healthcare record.
  • The accurate dispensing of both parenteral and oral cancer therapy and related treatment including supportive care therapies.
  • All components of the prescription are supplied in a timely and safe manner.
  • The preparation of parenteral cytotoxics is carried out using premises and equipment suitable for aseptic manipulation of the product according to risk and standards of practice.
  • The appropriate health and safety standards are applied when handling hazardous oral medications such as oral cytotoxics.
  • All professional and legal responsibilities are met with respect to dispensing of medication.
  • All materials used for patient education are comprehensive, suitable for the patient’s treatment and routinely updated.
  • Consensus based recommendation
Practice pointQuestion mark transparent.png

The pharmacist must be able to recognise situations where they need to seek advice and support from an appropriate source (e.g. senior colleague) and respond appropriately. In particular, where the complexity required exceeds their own personal level of competence, where the patient is from a specialised population the pharmacist is not familiar with (e.g. paediatrics) or where there is reason for concern about the patients suitability for the prescribed treatment (British Oncology Pharmacy Association, 2013).


The pharmacist should lead initiatives to standardise preparation procedures including reconstitution, dilution, and admixture methods for commonly used parenteral chemotherapy medications (Attilio, 1996).


The pharmacist should be an active member of the local governance committee and medication safety committee.


The pharmacist should regularly provide education to other cancer health professionals about medication safety and error reduction. Processes to report to the multidisciplinary team on near misses and trends should be in place.


The pharmacist should provide input and advice into the use of electronic information systems (including prescribing, dispensing and manufacturing) and liaise directly with software vendors on current and future needs.

  • Clinical_question:What are the responsibilities of the Pharmacist when dispensing and supplying cancer therapy?#Practice_point_2
  • The pharmacist must be able to recognise situations where they need to seek advice and support from an appropriate source (e.g. senior colleague) and respond appropriately. In particular, where the complexity required exceeds their own personal level of competence, where the patient is from a specialised population the pharmacist is not familiar with (e.g. paediatrics) or where there is reason for concern about the patients suitability for the prescribed treatment (British Oncology Pharmacy Association, 2013).

The pharmacist should lead initiatives to standardise preparation procedures including reconstitution, dilution, and admixture methods for commonly used parenteral chemotherapy medications (Attilio, 1996).


The pharmacist should be an active member of the local governance committee and medication safety committee.


The pharmacist should regularly provide education to other cancer health professionals about medication safety and error reduction. Processes to report to the multidisciplinary team on near misses and trends should be in place.


The pharmacist should provide input and advice into the use of electronic information systems (including prescribing, dispensing and manufacturing) and liaise directly with software vendors on current and future needs.

  • Good practice point

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What competencies and skills are required when dispensing and supplying cancer therapy?

Consensus-based recommendationQuestion mark transparent.png

All tasks involved in the provision of cancer therapy must only be undertaken by a cancer pharmacist who has undergone specialist training, demonstrated their appropriate competence and is locally authorised/accredited for the task (Goldspiel et al, 2015). This includes (but is not limited to) clinical verification of cancer therapy, monitoring of patients, dispensing of medications and education of patients.


All institutions and individual pharmacists must demonstrate competency in the domains of the National Competency Standards Framework for Pharmacists in Australia (Pharmaceutical Society of Australia, 2010) and in the Society of Hospital Pharmacists Clinical Competency Assessment Tool (Society of Hospital Pharmacists of Australia, 2013).


All institutions must ensure policies and procedures are in place for training, continuing education and assessment of competency of pharmacists responsible for tasks involved in the provision of cancer therapy including clinical verification of prescriptions, monitoring of patients and dispensing of medications for cancer treatment (Goldspiel et al, 2015; Carrington et al, 2011; Carrington et al, 2010; Neuss et al, 2017).


A pharmacist with a role in cancer should ensure that continuing professional education activities are relevant to the scope of role as a cancer pharmacist and meet the Pharmacy Board of Australia’s requirement for CPD credits (Pharmacy Board of Australia, 2015; Society of Hospital Pharmacists of Australia Committee of Specialty Practice in Oncology, 2002).


The pharmacist must demonstrate competence, knowledge and proficiency in techniques and procedures for safe handling and disposing of hazardous agents including cytotoxic therapies. These competencies should be reassessed at least annually (Goldspiel et al, 2015; Society of Hospital Pharmacists of Australia Committee of Specialty Practice in Cancer Services, 2007).


Pharmacists with insufficient knowledge or experience in cancer treatment should not be delegated to manage patients receiving chemotherapy and related treatment.

  • Clinical_question:What competencies and skills are required when dispensing and supplying cancer therapy?#Practice_point_1
  • All tasks involved in the provision of cancer therapy must only be undertaken by a cancer pharmacist who has undergone specialist training, demonstrated their appropriate competence and is locally authorised/accredited for the task (Goldspiel et al, 2015). This includes (but is not limited to) clinical verification of cancer therapy, monitoring of patients, dispensing of medications and education of patients.

All institutions and individual pharmacists must demonstrate competency in the domains of the National Competency Standards Framework for Pharmacists in Australia (Pharmaceutical Society of Australia, 2010) and in the Society of Hospital Pharmacists Clinical Competency Assessment Tool (Society of Hospital Pharmacists of Australia, 2013).


All institutions must ensure policies and procedures are in place for training, continuing education and assessment of competency of pharmacists responsible for tasks involved in the provision of cancer therapy including clinical verification of prescriptions, monitoring of patients and dispensing of medications for cancer treatment (Goldspiel et al, 2015; Carrington et al, 2011; Carrington et al, 2010; Neuss et al, 2017).


A pharmacist with a role in cancer should ensure that continuing professional education activities are relevant to the scope of role as a cancer pharmacist and meet the Pharmacy Board of Australia’s requirement for CPD credits (Pharmacy Board of Australia, 2015; Society of Hospital Pharmacists of Australia Committee of Specialty Practice in Oncology, 2002).


The pharmacist must demonstrate competence, knowledge and proficiency in techniques and procedures for safe handling and disposing of hazardous agents including cytotoxic therapies. These competencies should be reassessed at least annually (Goldspiel et al, 2015; Society of Hospital Pharmacists of Australia Committee of Specialty Practice in Cancer Services, 2007).


Pharmacists with insufficient knowledge or experience in cancer treatment should not be delegated to manage patients receiving chemotherapy and related treatment.

  • Consensus based recommendation
Practice pointQuestion mark transparent.png

A pharmacist working in cancer care without the direct supervision of a more senior pharmacist should have a minimum of 2 years previous experience in cancer working under a senior cancer pharmacist (Carrington et al, 2011).


Competencies should be reassessed at least annually or sooner where a member of staff has been absent from the work area for a substantial period of time.


A pharmacist working independently as a cancer pharmacist should hold, or be working towards a postgraduate qualification in clinical pharmacy (Carrington et al, 2011).


Cancer pharmacists should be encouraged to obtain formalised accreditation through the US Board of Pharmaceutical Specialties. Institutes should provide relevant support to enable pharmacists to undertake credentialing.


A pharmacist with a role in cancer should attend specialist cancer conferences, seminars and educational meetings to maintain and update specialist knowledge and skills.

  • Clinical_question:What competencies and skills are required when dispensing and supplying cancer therapy?#Practice_point_2
  • A pharmacist working in cancer care without the direct supervision of a more senior pharmacist should have a minimum of 2 years previous experience in cancer working under a senior cancer pharmacist (Carrington et al, 2011).

Competencies should be reassessed at least annually or sooner where a member of staff has been absent from the work area for a substantial period of time.


A pharmacist working independently as a cancer pharmacist should hold, or be working towards a postgraduate qualification in clinical pharmacy (Carrington et al, 2011).


Cancer pharmacists should be encouraged to obtain formalised accreditation through the US Board of Pharmaceutical Specialties. Institutes should provide relevant support to enable pharmacists to undertake credentialing.


A pharmacist with a role in cancer should attend specialist cancer conferences, seminars and educational meetings to maintain and update specialist knowledge and skills.

  • Good practice point

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What is the procedure for the Pharmacist when clinically verifying cancer prescriptions?

Consensus-based recommendationQuestion mark transparent.png

All prescribed cancer therapy and associated supportive care medications (by any route of administration) must be clinically verified by a pharmacist prior to dispensing and administration to, or by, a patient. Verification must be performed according to the protocol and the patient’s treatment plan and individual parameters (Goldspiel et al, 2015; Carrington et al, 2010).

The five “P”s should be followed to successfully verify a cancer therapy medication order:

1. Patient details and dosing variables

2. Prescription/medication order

3. Protocol and scheduling

4. Prescribed medication, dose calculations and administration

5. Patient organ function and laboratory blood tests

Table 11 provides recommendations on details that must be verified by the pharmacist.


The pharmacy verification process must be documented in an up-to-date local procedure which outlines the individual systematic checks that pharmacists are required to undertake when verifying cancer medication orders prior to dispensing, supply and administration.


Any identified discrepancies, anomalies or errors must be clarified and resolved with the prescriber. All significant interventions should be documented in the patients’ healthcare record.


The pharmacist responsible for the verification must sign and date each cancer medication order to confirm verification has been completed. Where electronic medication management systems are in use the pharmacist must ensure that electronic verification is performed securely and in line with local procedures and state legislation.


A patient medication history must be taken from the patient and documented on first cycle of chemotherapy or when the protocol is changed (Australian Pharmaceutical Advisory Council, 2005; The Society of Hospital Pharmacists of Australia, 2013). The pharmacist must ensure regular review with the patient that captures any changes to the patients usual medications or commencement of new medications. The pharmacist must maintain an up-to-date treatment history relating to all chemotherapy medications, doses, variations and treatment dates (Carrington et al, 2010).

  • Clinical_question:What is the procedure for the Pharmacist when clinically verifying cancer prescriptions?#Practice_point_1
  • All prescribed cancer therapy and associated supportive care medications (by any route of administration) must be clinically verified by a pharmacist prior to dispensing and administration to, or by, a patient. Verification must be performed according to the protocol and the patient’s treatment plan and individual parameters (Goldspiel et al, 2015; Carrington et al, 2010).

The five “P”s should be followed to successfully verify a cancer therapy medication order:

1. Patient details and dosing variables

2. Prescription/medication order

3. Protocol and scheduling

4. Prescribed medication, dose calculations and administration

5. Patient organ function and laboratory blood tests

Table 11 provides recommendations on details that must be verified by the pharmacist.


The pharmacy verification process must be documented in an up-to-date local procedure which outlines the individual systematic checks that pharmacists are required to undertake when verifying cancer medication orders prior to dispensing, supply and administration.


Any identified discrepancies, anomalies or errors must be clarified and resolved with the prescriber. All significant interventions should be documented in the patients’ healthcare record.


The pharmacist responsible for the verification must sign and date each cancer medication order to confirm verification has been completed. Where electronic medication management systems are in use the pharmacist must ensure that electronic verification is performed securely and in line with local procedures and state legislation.


A patient medication history must be taken from the patient and documented on first cycle of chemotherapy or when the protocol is changed (Australian Pharmaceutical Advisory Council, 2005; The Society of Hospital Pharmacists of Australia, 2013). The pharmacist must ensure regular review with the patient that captures any changes to the patients usual medications or commencement of new medications. The pharmacist must maintain an up-to-date treatment history relating to all chemotherapy medications, doses, variations and treatment dates (Carrington et al, 2010).

  • Consensus based recommendation
Practice pointQuestion mark transparent.png

Physical and staffing resources should enable the pharmacist to verify all cancer medication orders and prescriptions away from distractions and interruptions to maximise safety.


An independent check should be performed by a second pharmacist with appropriate training and demonstrated competence in verifying cancer therapy when possible and supported by staffing resources. This should include a check of any manual dosage calculations.


When a patient is admitted to hospital and is already receiving cancer chemotherapy or targeted therapy (oral or parenteral) the original prescriber or an appropriate clinician with experience in haematology/oncology must be contacted to verify whether cancer therapy is to continue or whether dose adjustments or withholding of therapy is necessary.


Certain populations may be at increased risk of toxicities from chemotherapy (e.g. patients with chromosomal abnormalities including Down Syndrome, Ataxia Telangiectasia and Fanconi Anaemia etc). These patients require careful consideration for dosing, particularly chemotherapy. Documented guidelines should be followed for chemotherapy dosing in obese patients where there is limited guidance available within the patient’s protocol.

  • Clinical_question:What is the procedure for the Pharmacist when clinically verifying cancer prescriptions?#Practice_point_2
  • Physical and staffing resources should enable the pharmacist to verify all cancer medication orders and prescriptions away from distractions and interruptions to maximise safety.

An independent check should be performed by a second pharmacist with appropriate training and demonstrated competence in verifying cancer therapy when possible and supported by staffing resources. This should include a check of any manual dosage calculations.


When a patient is admitted to hospital and is already receiving cancer chemotherapy or targeted therapy (oral or parenteral) the original prescriber or an appropriate clinician with experience in haematology/oncology must be contacted to verify whether cancer therapy is to continue or whether dose adjustments or withholding of therapy is necessary.


Certain populations may be at increased risk of toxicities from chemotherapy (e.g. patients with chromosomal abnormalities including Down Syndrome, Ataxia Telangiectasia and Fanconi Anaemia etc). These patients require careful consideration for dosing, particularly chemotherapy. Documented guidelines should be followed for chemotherapy dosing in obese patients where there is limited guidance available within the patient’s protocol.

  • Good practice point

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How should information be presented on a medication label for cancer therapy to minimise errors?

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A documented procedure for the labelling of all medications for administration by all routes in the inpatient and outpatient setting should be available.


A uniform labelling template that presents information in a consistent manner should be adopted to ensure easy identification of the medication, route, dose and patient (Neuss, 2017; Goldspiel, 2015; Carrington, 2010).

  • Clinical_question:How should information be presented on a medication label for cancer therapy to minimise errors?#Practice_point_1
  • A documented procedure for the labelling of all medications for administration by all routes in the inpatient and outpatient setting should be available.

A uniform labelling template that presents information in a consistent manner should be adopted to ensure easy identification of the medication, route, dose and patient (Neuss, 2017; Goldspiel, 2015; Carrington, 2010).

  • Consensus based recommendation
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Labels should be applied immediately after preparation of a medication.


Labels should not obscure the product name, batch number, expiry date or scannable barcode of the original packaging or diluent container.


Rate and duration of administration on parenteral products should be specified to assist nursing staff in selecting the correct rate.


Medication labels should be mechanically printed in permanent ink (not handwritten).


The minimum font size for patient name, medication name and dose should be 12 point or equivalent as larger font sizes result in fewer reading errors (Trudeau, 2009; Institute for Safe Medication Practices, 2010).


Refrigeration can reduce the adhesiveness of labels causing them to become detached from the product. Adhesive strength of the labels should be such that the labels do not detach from the medication. Removable labels should not be used.


The labelling of nurse prepared medications must comply with the National Standard for User Applied Labelling (Australian Commission on Safety and Quality in Health Care, 2015).

  • Clinical_question:How should information be presented on a medication label for cancer therapy to minimise errors?#Practice_point_2
  • Labels should be applied immediately after preparation of a medication.

Labels should not obscure the product name, batch number, expiry date or scannable barcode of the original packaging or diluent container.


Rate and duration of administration on parenteral products should be specified to assist nursing staff in selecting the correct rate.


Medication labels should be mechanically printed in permanent ink (not handwritten).


The minimum font size for patient name, medication name and dose should be 12 point or equivalent as larger font sizes result in fewer reading errors (Trudeau, 2009; Institute for Safe Medication Practices, 2010).


Refrigeration can reduce the adhesiveness of labels causing them to become detached from the product. Adhesive strength of the labels should be such that the labels do not detach from the medication. Removable labels should not be used.


The labelling of nurse prepared medications must comply with the National Standard for User Applied Labelling (Australian Commission on Safety and Quality in Health Care, 2015).

  • Good practice point

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What safety processes should be followed for preparation and delivery of cancer therapy?

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The preparation process must ensure that the therapy is stable in the required container and diluent for the required length of time. Where preparation is carried out by a third party compounder the institution must be satisfied that the products are prepared in accordance with appropriate standards. Consideration should be given to whether the compounder holds a manufacturing licence from the Therapeutic Goods Administration (TGA) for the relevant compounding site.


A reconciliation check with the product and the medication order must be carried out by the pharmacist before administration to the patient. The pharmacist doing the reconciliation check should not be the pharmacist that has clinically verified the order. Sufficient staff resources should be allocated to ensure this is possible.


Where preparation is carried out by a third party or external compounder/manufacturer there must be a process in place to ensure the final prepared product is checked against the medication order by a pharmacist at the institute where the cancer therapy is to be administered. The process should include a check against the original medication order before the product is provided to nursing staff for administration to the patient.


All cytotoxic chemotherapy must be delivered and stored separately from other non-cytotoxic products in an area and container dedicated to the purpose. The storage location and container must be labelled as such. Monoclonal antibodies and oral targeted therapies should be stored and delivered separately to cytotoxic chemotherapy where practical. A local risk assessment should be in place to support the preparation and delivery of monoclonal antibodies (Alexander et al, 2014).


Intrathecal chemotherapy has special requirements for preparation, transportation and delivery.


Appropriate information on stability and safety must be obtained before preparation where requests are made for products to be prepared outside of standard formulations or for administration via non-standard routes.

  • Clinical_question:What safety processes should be followed for preparation and delivery of cancer therapy?#Practice_point_1
  • The preparation process must ensure that the therapy is stable in the required container and diluent for the required length of time. Where preparation is carried out by a third party compounder the institution must be satisfied that the products are prepared in accordance with appropriate standards. Consideration should be given to whether the compounder holds a manufacturing licence from the Therapeutic Goods Administration (TGA) for the relevant compounding site.

A reconciliation check with the product and the medication order must be carried out by the pharmacist before administration to the patient. The pharmacist doing the reconciliation check should not be the pharmacist that has clinically verified the order. Sufficient staff resources should be allocated to ensure this is possible.


Where preparation is carried out by a third party or external compounder/manufacturer there must be a process in place to ensure the final prepared product is checked against the medication order by a pharmacist at the institute where the cancer therapy is to be administered. The process should include a check against the original medication order before the product is provided to nursing staff for administration to the patient.


All cytotoxic chemotherapy must be delivered and stored separately from other non-cytotoxic products in an area and container dedicated to the purpose. The storage location and container must be labelled as such. Monoclonal antibodies and oral targeted therapies should be stored and delivered separately to cytotoxic chemotherapy where practical. A local risk assessment should be in place to support the preparation and delivery of monoclonal antibodies (Alexander et al, 2014).


Intrathecal chemotherapy has special requirements for preparation, transportation and delivery.


Appropriate information on stability and safety must be obtained before preparation where requests are made for products to be prepared outside of standard formulations or for administration via non-standard routes.

  • Consensus based recommendation

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What is best practice when dispensing oral cancer treatment (chemotherapy and targeted therapy)?

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Verification


Prescriptions for oral cancer medications must be clinically verified by a pharmacist with appropriate training and skills in cancer pharmacy prior to being dispensed (Society of Hospital Pharmacists of Australia Committee of Specialty Practice in Cancer Services, 2007; Carrington et al, 2010; Rudnitzki and McMahon, 2015; British Oncology Pharmacy Association, 2013).


Prescriptions for oral cancer therapies should be verified using the same procedures and safety standards as those used to verify cancer therapy administered via other routes. In addition, the following should be verified:

  • The orders for both oral and parenteral cancer agents must be clinically verified at the same time if oral cancer medications are prescribed in conjunction with cancer medications administered via other routes (e.g. the treatment protocol XELOX contains intravenous oxaliplatin and oral capecitabine).
  • The duration of treatment for the oral cancer medication is clear and correct according to the protocol, and there is no ambiguity with regards to continuous and intermittent dosing. Intermittent dosing should be clearly stated as the defined duration treatment is required within the cycle (e.g. Temozolomide on days 1 to 5 inclusive in a 28 day cycle or Capecitabine days 1 to 14 inclusive in a 21 day cycle).
  • Where therapy is being administered for a defined cycle duration, the start and stop dates are stated and appropriate according to the protocol.
  • The dose prescribed can be safely administered using the strengths and formulations of medications that are available.
  • All supportive therapy required has been prescribed and is appropriate for the duration including antiemetics, anti-diarrhoeals and anti-infectives. Growth factor support may still be required with some protocols containing oral cancer therapy.

Dispensing


For oral cancer therapies administered for a finite course or stated duration, the quantity supplied should only be the quantity of tablets/capsules the patient requires for that cycle of treatment (Society of Hospital Pharmacists of Australia Committee of Specialty Practice in Cancer Services, 2007; Carrington et al, 2010). This type of intermittent scheduling is common with the traditional cytotoxic oral agents such as capecitabine, cyclophosphamide, melphalan, methotrexate etc.

This quantity may be less than the allowed PBS prescribed quantity however the use of PBS quantities as whole patient packs may pose a risk to patients if they contain more tablets than are needed for the cycle. If the amount supplied overrides the prescribed PBS quantity, then this should be documented and endorsed on the prescription/order.


For non-cyclical continuous cancer therapy, usually molecular targeted therapy, the exact quantity of oral cancer agent(s) required for that cycle of therapy should be supplied or until the next review is due. It is usual practice to provide one month’s supply per dispensing and for the patient to be reviewed monthly (or more frequently) until they are established on the therapy (Institute for Safe Medication Practices, 2014; Phillips, 2003; NHS National Patient Safety Agency UK, 2008).


Oral cancer medications are often classified as cytotoxic or hazardous agents. Pharmacists should refer to state and national guidelines and legislation for guidance on the safe handling of cytotoxic and hazardous agents. Oral cancer therapies should be stored in designated areas in a dispensary and be clearly labelled. Where more than one strength is available (e.g. capecitabine 150mg & 500mg or temozolomide with strengths ranging from 5mg to 180mg capsules), steps should be in place to adequately separate stock to minimise the risk of stock being incorrectly picked from the shelf.


Patient education


Pharmacists have a professional responsibility to provide patients with adequate written and verbal education to use medications safely and effectively (Pharmacy Board of Australia, 2015). The Patient Information section of these guidelines includes the requirements for patient education and provision of information regarding cancer therapy including chemotherapy, targeted therapy and supportive therapies and additional education requirements for oral cancer therapies.

  • Clinical_question:What is best practice when dispensing oral cancer treatment (chemotherapy and targeted therapy)?#Practice_point_1
  • Verification

Prescriptions for oral cancer medications must be clinically verified by a pharmacist with appropriate training and skills in cancer pharmacy prior to being dispensed (Society of Hospital Pharmacists of Australia Committee of Specialty Practice in Cancer Services, 2007; Carrington et al, 2010; Rudnitzki and McMahon, 2015; British Oncology Pharmacy Association, 2013).


Prescriptions for oral cancer therapies should be verified using the same procedures and safety standards as those used to verify cancer therapy administered via other routes. In addition, the following should be verified:

  • The orders for both oral and parenteral cancer agents must be clinically verified at the same time if oral cancer medications are prescribed in conjunction with cancer medications administered via other routes (e.g. the treatment protocol XELOX contains intravenous oxaliplatin and oral capecitabine).
  • The duration of treatment for the oral cancer medication is clear and correct according to the protocol, and there is no ambiguity with regards to continuous and intermittent dosing. Intermittent dosing should be clearly stated as the defined duration treatment is required within the cycle (e.g. Temozolomide on days 1 to 5 inclusive in a 28 day cycle or Capecitabine days 1 to 14 inclusive in a 21 day cycle).
  • Where therapy is being administered for a defined cycle duration, the start and stop dates are stated and appropriate according to the protocol.
  • The dose prescribed can be safely administered using the strengths and formulations of medications that are available.
  • All supportive therapy required has been prescribed and is appropriate for the duration including antiemetics, anti-diarrhoeals and anti-infectives. Growth factor support may still be required with some protocols containing oral cancer therapy.

Dispensing


For oral cancer therapies administered for a finite course or stated duration, the quantity supplied should only be the quantity of tablets/capsules the patient requires for that cycle of treatment (Society of Hospital Pharmacists of Australia Committee of Specialty Practice in Cancer Services, 2007; Carrington et al, 2010). This type of intermittent scheduling is common with the traditional cytotoxic oral agents such as capecitabine, cyclophosphamide, melphalan, methotrexate etc.

This quantity may be less than the allowed PBS prescribed quantity however the use of PBS quantities as whole patient packs may pose a risk to patients if they contain more tablets than are needed for the cycle. If the amount supplied overrides the prescribed PBS quantity, then this should be documented and endorsed on the prescription/order.


For non-cyclical continuous cancer therapy, usually molecular targeted therapy, the exact quantity of oral cancer agent(s) required for that cycle of therapy should be supplied or until the next review is due. It is usual practice to provide one month’s supply per dispensing and for the patient to be reviewed monthly (or more frequently) until they are established on the therapy (Institute for Safe Medication Practices, 2014; Phillips, 2003; NHS National Patient Safety Agency UK, 2008).


Oral cancer medications are often classified as cytotoxic or hazardous agents. Pharmacists should refer to state and national guidelines and legislation for guidance on the safe handling of cytotoxic and hazardous agents. Oral cancer therapies should be stored in designated areas in a dispensary and be clearly labelled. Where more than one strength is available (e.g. capecitabine 150mg & 500mg or temozolomide with strengths ranging from 5mg to 180mg capsules), steps should be in place to adequately separate stock to minimise the risk of stock being incorrectly picked from the shelf.


Patient education


Pharmacists have a professional responsibility to provide patients with adequate written and verbal education to use medications safely and effectively (Pharmacy Board of Australia, 2015). The Patient Information section of these guidelines includes the requirements for patient education and provision of information regarding cancer therapy including chemotherapy, targeted therapy and supportive therapies and additional education requirements for oral cancer therapies.

  • Consensus based recommendation
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Staff dispensing oral cancer medicines in the community setting or community pharmacies must have appropriate skills and training to verify oral cancer therapy. They must have access to all relevant treatment information and patient parameters to ensure they can confirm that the prescribed treatments and dose are appropriate for the patient. Access to a cancer pharmacist at the hospital/institute where the therapy has been initiated is important to clarify treatment related questions. The eviQ Cancer Education Online module “Cancer Medicines - the role that community pharmacists play in supporting their customers” provides practical learning activities addressing issues encountered in the community pharmacy setting (Cancer Institute NSW, 2017).


Dispensing chemotherapy from repeat prescriptions should be discouraged as changes can often occur to prescriptions due to clinical reasons. Where this is unavoidable, repeat prescriptions for subsequent cycles of oral cancer medicines should be confirmed with the prescriber before dispensing to ensure there has been no change to dose or treatment since the initial prescription was written. A chemotherapy order should also accompany the script. Where a change has been made, a new prescription should be requested and the old prescription/repeats destroyed (Society of Hospital Pharmacists of Australia Committee of Specialty Practice in Cancer Services, 2007).


Further discussions with clinicians and patients may be needed if a patient returns unused quantities of oral cancer medication with no clinical rationale or a patient runs out of supply before expected according to the dose prescribed. This may indicate over compliance, mis-dosing or non-adherence (Taylor et al, 2006; Spoelstra and Given, 2011; Spoelstra et al, 2013).


Child-proof caps must be used when dispensing non-blister packs or containers of oral chemotherapy (Society of Hospital Pharmacists of Australia Committee of Specialty Practice in Cancer Services, 2007).


Barcode scanning of product and computer generated labels should be used when dispensing oral chemotherapy (Weingart et al, 2011; Pharmacy Board of Australia, 2015).


Oral cancer agents should not be made available as imprest or ward stock (Society of Hospital Pharmacists of Australia Committee of Specialty Practice in Cancer Services, 2007).

  • Clinical_question:What is best practice when dispensing oral cancer treatment (chemotherapy and targeted therapy)?#Practice_point_2
  • Staff dispensing oral cancer medicines in the community setting or community pharmacies must have appropriate skills and training to verify oral cancer therapy. They must have access to all relevant treatment information and patient parameters to ensure they can confirm that the prescribed treatments and dose are appropriate for the patient. Access to a cancer pharmacist at the hospital/institute where the therapy has been initiated is important to clarify treatment related questions. The eviQ Cancer Education Online module “Cancer Medicines - the role that community pharmacists play in supporting their customers” provides practical learning activities addressing issues encountered in the community pharmacy setting (Cancer Institute NSW, 2017).

Dispensing chemotherapy from repeat prescriptions should be discouraged as changes can often occur to prescriptions due to clinical reasons. Where this is unavoidable, repeat prescriptions for subsequent cycles of oral cancer medicines should be confirmed with the prescriber before dispensing to ensure there has been no change to dose or treatment since the initial prescription was written. A chemotherapy order should also accompany the script. Where a change has been made, a new prescription should be requested and the old prescription/repeats destroyed (Society of Hospital Pharmacists of Australia Committee of Specialty Practice in Cancer Services, 2007).


Further discussions with clinicians and patients may be needed if a patient returns unused quantities of oral cancer medication with no clinical rationale or a patient runs out of supply before expected according to the dose prescribed. This may indicate over compliance, mis-dosing or non-adherence (Taylor et al, 2006; Spoelstra and Given, 2011; Spoelstra et al, 2013).


Child-proof caps must be used when dispensing non-blister packs or containers of oral chemotherapy (Society of Hospital Pharmacists of Australia Committee of Specialty Practice in Cancer Services, 2007).


Barcode scanning of product and computer generated labels should be used when dispensing oral chemotherapy (Weingart et al, 2011; Pharmacy Board of Australia, 2015).


Oral cancer agents should not be made available as imprest or ward stock (Society of Hospital Pharmacists of Australia Committee of Specialty Practice in Cancer Services, 2007).

  • Good practice point

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What is best practice when dispensing and supplying intrathecal therapy?

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All staff involved in the dispensing of intrathecal therapy should undergo appropriate training and be assessed as competent to perform their roles and responsibilities regarding intrathecal therapy.


The pharmacist must ensure:

  • The prescription or order for intrathecal chemotherapy is complete and correct as per national and local policies and procedures.
  • The clinical verification of the intrathecal chemotherapy order is performed according to the protocol, the patient’s treatment plan and patient parameters.
  • Local procedures for manufacturing and delivery of intrathecal chemotherapy are adhered to in order to eliminate risk of misadventure related to intrathecal therapy. All intrathecal therapy must be delivered and stored separately to cytotoxic chemotherapy administered by other routes.
  • All staff involved in the verification, manufacturing checking and distribution of intrathecal chemotherapy are trained and appropriately validated as per local policy.
  • Clinical_question:What is best practice when dispensing and supplying intrathecal therapy?#Practice_point_1
  • All staff involved in the dispensing of intrathecal therapy should undergo appropriate training and be assessed as competent to perform their roles and responsibilities regarding intrathecal therapy.

The pharmacist must ensure:

  • The prescription or order for intrathecal chemotherapy is complete and correct as per national and local policies and procedures.
  • The clinical verification of the intrathecal chemotherapy order is performed according to the protocol, the patient’s treatment plan and patient parameters.
  • Local procedures for manufacturing and delivery of intrathecal chemotherapy are adhered to in order to eliminate risk of misadventure related to intrathecal therapy. All intrathecal therapy must be delivered and stored separately to cytotoxic chemotherapy administered by other routes.
  • All staff involved in the verification, manufacturing checking and distribution of intrathecal chemotherapy are trained and appropriately validated as per local policy.
  • Consensus based recommendation
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Pharmacists should be aware of the risks of inadvertent administration of chemotherapy by the incorrect route irrespective of whether the institute administers cytotoxic chemotherapy via the intrathecal route (Gilbar and Seger, 2013; Society of Hospital Pharmacists of Australia, 2005).

  • Clinical_question:What is best practice when dispensing and supplying intrathecal therapy?#Practice_point_2
  • Pharmacists should be aware of the risks of inadvertent administration of chemotherapy by the incorrect route irrespective of whether the institute administers cytotoxic chemotherapy via the intrathecal route (Gilbar and Seger, 2013; Society of Hospital Pharmacists of Australia, 2005).
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Role of the Nurse

What are the responsibilities of the Nurse when administering cancer therapy?

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The nurse is responsible for ensuring:

  • Family, carers or others are adequately informed about the treatment and administration process. Education and information should be based on the patient’s reading level and literacy and level of understanding of information provided (Neuss et al, 2017).
  • Patient education and consent processes have been completed and documented according to local institute requirements.
  • The planned treatment is verified with the patient and understood by them (Neuss et al, 2017).
  • All medication is stored appropriately prior to administration.
  • Independent verification of the medication order (including chemotherapy, targeted therapy and supportive medication) according to the protocol, the patient’s treatment plan, patient laboratory parameters and other individual parameters.
  • The therapy and associated treatments are administered to the patient in a safe and timely manner.
  • Any immediate and longer term effects are appropriately managed.
  • All professional and legal responsibilities with respect to administration of medications are met.
  • Clinical_question:What are the responsibilities of the Nurse when administering cancer therapy?#Practice_point_1
  • The nurse is responsible for ensuring:
  • Family, carers or others are adequately informed about the treatment and administration process. Education and information should be based on the patient’s reading level and literacy and level of understanding of information provided (Neuss et al, 2017).
  • Patient education and consent processes have been completed and documented according to local institute requirements.
  • The planned treatment is verified with the patient and understood by them (Neuss et al, 2017).
  • All medication is stored appropriately prior to administration.
  • Independent verification of the medication order (including chemotherapy, targeted therapy and supportive medication) according to the protocol, the patient’s treatment plan, patient laboratory parameters and other individual parameters.
  • The therapy and associated treatments are administered to the patient in a safe and timely manner.
  • Any immediate and longer term effects are appropriately managed.
  • All professional and legal responsibilities with respect to administration of medications are met.
  • Consensus based recommendation

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What competencies and skills are required when administering cancer therapy?

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Nurses administering cancer therapies should be competent in age-appropriate basic life support (Neuss et al, 2017; Belderson and Billett, 2017).


All nurses administering chemotherapy, targeted therapy, monoclonal therapy for cancer and related treatments should have access to appropriate educational resources and relevant standards and legislation (Vioral, 2014).

Education programs must have clear and unambiguous learning objectives underpinned by relevant aspects of The National Cancer Nursing Education Project (EdCaN, 2009). Education programs must include strategies to ensure staff are kept up-to-date with new therapies, new protocols and new devices that are introduced into clinical practice and can access relevant information. With the increasing number of new non-chemotherapy medicines (e.g. monoclonal immunotherapies) being introduced into clinical practice, nursing staff must ensure understanding and competency to administer these therapies and provide patient support.


Nurses must demonstrate competence, knowledge and proficiency in the administration of cancer therapy and related aspects of cancer care. Competencies to be completed include:

  • Evidence based education program in the delivery of cancer chemotherapy via different routes. For example: eviQ Cancer Education Online "Antineoplastic Drug Administration Course (ADAC)" (Cancer Institute NSW, 2017).
  • Evidence based education program in the management and maintenance of central venous access devices. For example: eviQ Cancer Education Online "Central Venous Access Device Course" (Cancer Institute NSW, 2017).
  • Nurses administering chemotherapy to paediatric patients should have completed a specific paediatric chemotherapy education program. For example: eviQ Cancer Education Online "Paediatric Antineoplastic Drug Administration Course" (Cancer Institute NSW, 2017).

Nurses should maintain their competency and skills in the administration of chemotherapy through ongoing learning and regular competence based assessment. Staff who are competent in the administration of cancer therapy and management of cancer patients should support and facilitate training. Nurses with a role in cancer should attend specialist cancer conferences, seminars and educational meetings to maintain and update specialist knowledge and skills. Competencies to be completed include:

  • Evidence based education program for the maintenance of clinical competency in the delivery of cancer chemotherapy via different routes. For example: eviQ Cancer Education Online "ADAC reassessment of Clinical Competency" (Cancer Institute NSW, 2017).
  • Clinical_question:What competencies and skills are required when administering cancer therapy?#Practice_point_1
  • Nurses administering cancer therapies should be competent in age-appropriate basic life support (Neuss et al, 2017; Belderson and Billett, 2017).

All nurses administering chemotherapy, targeted therapy, monoclonal therapy for cancer and related treatments should have access to appropriate educational resources and relevant standards and legislation (Vioral, 2014).

Education programs must have clear and unambiguous learning objectives underpinned by relevant aspects of The National Cancer Nursing Education Project (EdCaN, 2009). Education programs must include strategies to ensure staff are kept up-to-date with new therapies, new protocols and new devices that are introduced into clinical practice and can access relevant information. With the increasing number of new non-chemotherapy medicines (e.g. monoclonal immunotherapies) being introduced into clinical practice, nursing staff must ensure understanding and competency to administer these therapies and provide patient support.


Nurses must demonstrate competence, knowledge and proficiency in the administration of cancer therapy and related aspects of cancer care. Competencies to be completed include:

  • Evidence based education program in the delivery of cancer chemotherapy via different routes. For example: eviQ Cancer Education Online "Antineoplastic Drug Administration Course (ADAC)" (Cancer Institute NSW, 2017).
  • Evidence based education program in the management and maintenance of central venous access devices. For example: eviQ Cancer Education Online "Central Venous Access Device Course" (Cancer Institute NSW, 2017).
  • Nurses administering chemotherapy to paediatric patients should have completed a specific paediatric chemotherapy education program. For example: eviQ Cancer Education Online "Paediatric Antineoplastic Drug Administration Course" (Cancer Institute NSW, 2017).

Nurses should maintain their competency and skills in the administration of chemotherapy through ongoing learning and regular competence based assessment. Staff who are competent in the administration of cancer therapy and management of cancer patients should support and facilitate training. Nurses with a role in cancer should attend specialist cancer conferences, seminars and educational meetings to maintain and update specialist knowledge and skills. Competencies to be completed include:

  • Evidence based education program for the maintenance of clinical competency in the delivery of cancer chemotherapy via different routes. For example: eviQ Cancer Education Online "ADAC reassessment of Clinical Competency" (Cancer Institute NSW, 2017).
  • Consensus based recommendation

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What information and assessments are required prior to administering cancer therapy?

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The following information should be made available prior to commencing the administration of cancer therapy (Polovich et al, 2014; Neuss et al, 2017; Belderson and Billett, 2017; Carrington et al, 2010):

  • Current diagnosis.
  • Medical history.
  • Medication and cancer treatment history.
  • The signed patient (or caregiver) consent, and where appropriate documented patient assent, according to local policy.
  • Allergies and history of any hypersensitivity reactions. If no allergies are known this must be documented on the medication chart and in the patient healthcare record.
  • A treatment plan.
  • An original and legible medication order.
  • Patient parameters (height, weight, BSA, age) and relevant laboratory values including full blood count, creatinine, urea and electrolytes and liver function tests. Depending on the treatment plan other tests may be necessary. Nursing staff should confirm the performance of required tests and results and contact the medical officer where results fall outside acceptable parameters.
  • Product information related to the cancer therapy and supportive therapy to be administered. The nursing staff administering the cancer therapy and related therapy must ensure they are familiar with the medications to be administered and any immediate expected side effects.
  • Policies, procedures and equipment required for the safe administration and handling of cytotoxic chemotherapy, non-cytotoxic cancer therapy and related waste. This includes policies and procedures for safe medication administration, management of extravasation and emergency procedure protocols (Carrington et al, 2010; Clinical Oncology Society of Australia and Cancer Pharmacists Group of Australia, 2013; Goldspiel et al, 2015; Neuss et al, 2017).

The following assessments must be completed prior to commencing the administration of cancer therapy (Neuss et al, 2017; Polovich et al, 2014; Carrington et al, 2010):

  • An assessment of the patient should be carried out according to Table 13 including a performance status assessment (Oken et al, 1982).
  • Questions regarding compliance, treatment tolerance, psychosocial concerns and adverse events must be addressed with the patient prior to administration.
  • The order should be verified and any discrepancies identified discussed with the prescribing medical doctor and/or pharmacist prior to administration of the medication(s). Documentation of any discrepancy and the resolution must be completed. Physical and staffing resources should enable the nurse to check an order away from distractions and interruptions to maximise safety.
  • Sufficient time is available to safely administer all components of the therapy according to the protocol including observation time and that staff will be able to support their responsibilities (nursing, pharmacy and medical) during and after administration.

The following medication and equipment must be available prior to commencing the administration of cancer therapy:

  • All cancer therapy and medication to be administered, including pre-medications and intravenous fluids.
  • Personal protective equipment (PPE), consumables, infusion pumps and other related equipment needed to safely administer and monitor cancer therapy (e.g. extravasation management kit).

An appropriately qualified and trained registered nurse or nurse practitioner must be available during and after administration of cancer therapy. A medical officer with suitable experience must also be available in close proximity to respond to emergencies related to the administration of the therapy. The proximity and response time of the medical officer should be defined by local policy but should not compromise patient safety.


Pre-treatment medications


Administration of pre-medications must allow an appropriate time span to elapse before chemotherapy, targeted therapy and biological therapy is administered.

  • For most antiemetics 30 minutes is the minimum time period required before chemotherapy is administered following administration of the pre-medication, however this time may vary according to route of administration and time of onset of action of the medication.
  • Pre-medications should not be given too early (usually > 60 minutes prior to the dose) unless specified, as this may lead to insufficient therapeutic levels of the medication when therapy is given. Where information is not contained in a protocol, advice should be sought from a pharmacist.

Pre-medication steroids such as dexamethasone may be self-administered by the patient at home prior to therapy. A check should always be performed with the patient to ascertain if the patient has self-administered prescribed pre-treatment medications.

  • Clinical_question:What information and assessments are required prior to administering cancer therapy?#Practice_point_1
  • The following information should be made available prior to commencing the administration

of cancer therapy (Polovich et al, 2014; Neuss et al, 2017; Belderson and Billett, 2017; Carrington et al, 2010):

  • Current diagnosis.
  • Medical history.
  • Medication and cancer treatment history.
  • The signed patient (or caregiver) consent, and where appropriate documented patient assent, according to local policy.
  • Allergies and history of any hypersensitivity reactions. If no allergies are known this must be documented on the medication chart and in the patient healthcare record.
  • A treatment plan.
  • An original and legible medication order.
  • Patient parameters (height, weight, BSA, age) and relevant laboratory values including full blood count, creatinine, urea and electrolytes and liver function tests. Depending on the treatment plan other tests may be necessary. Nursing staff should confirm the performance of required tests and results and contact the medical officer where results fall outside acceptable parameters.
  • Product information related to the cancer therapy and supportive therapy to be administered. The nursing staff administering the cancer therapy and related therapy must ensure they are familiar with the medications to be administered and any immediate expected side effects.
  • Policies, procedures and equipment required for the safe administration and handling of cytotoxic chemotherapy, non-cytotoxic cancer therapy and related waste. This includes policies and procedures for safe medication administration, management of extravasation and emergency procedure protocols (Carrington et al, 2010; Clinical Oncology Society of Australia and Cancer Pharmacists Group of Australia, 2013; Goldspiel et al, 2015; Neuss et al, 2017).

The following assessments must be completed prior to commencing the administration of cancer therapy (Neuss et al, 2017; Polovich et al, 2014; Carrington et al, 2010):

  • An assessment of the patient should be carried out according to Table 13 including a performance status assessment (Oken et al, 1982).
  • Questions regarding compliance, treatment tolerance, psychosocial concerns and adverse events must be addressed with the patient prior to administration.
  • The order should be verified and any discrepancies identified discussed with the prescribing medical doctor and/or pharmacist prior to administration of the medication(s). Documentation of any discrepancy and the resolution must be completed. Physical and staffing resources should enable the nurse to check an order away from distractions and interruptions to maximise safety.
  • Sufficient time is available to safely administer all components of the therapy according to the protocol including observation time and that staff will be able to support their responsibilities (nursing, pharmacy and medical) during and after administration.

The following medication and equipment must be available prior to commencing the administration of cancer therapy:

  • All cancer therapy and medication to be administered, including pre-medications and intravenous fluids.
  • Personal protective equipment (PPE), consumables, infusion pumps and other related equipment needed to safely administer and monitor cancer therapy (e.g. extravasation management kit).

An appropriately qualified and trained registered nurse or nurse practitioner must be available during and after administration of cancer therapy. A medical officer with suitable experience must also be available in close proximity to respond to emergencies related to the administration of the therapy. The proximity and response time of the medical officer should be defined by local policy but should not compromise patient safety.


Pre-treatment medications


Administration of pre-medications must allow an appropriate time span to elapse before chemotherapy, targeted therapy and biological therapy is administered.

  • For most antiemetics 30 minutes is the minimum time period required before chemotherapy is administered following administration of the pre-medication, however this time may vary according to route of administration and time of onset of action of the medication.
  • Pre-medications should not be given too early (usually > 60 minutes prior to the dose) unless specified, as this may lead to insufficient therapeutic levels of the medication when therapy is given. Where information is not contained in a protocol, advice should be sought from a pharmacist.

Pre-medication steroids such as dexamethasone may be self-administered by the patient at home prior to therapy. A check should always be performed with the patient to ascertain if the patient has self-administered prescribed pre-treatment medications.

  • Consensus based recommendation

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What is the procedure for the Nurse when verifying cancer therapy and related medication prior to administration?

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The verification process must be documented in an up-to-date local procedure which outlines the individual systematic checks that nurses are required to undertake when verifying cancer medication orders and the medication prior to administration.


The checking process must not occur until the pharmacist’s verification process has been completed. The checking process must include a verification of the medication order AND a check that the medication to be administered is that prescribed on the order and intended to be administered by the prescriber (Australian Commission on Safety and Quality in Health Care, 2012).


The medication order and chemotherapy, targeted therapy and related medications must be checked at the point of administration by two registered nurses with the appropriate training and skills (Goldspiel et al, 2015; Neuss et al, 2017; White et al, 2010). The checking process by the two nurses should occur independently. Where a second nurse is not available then a pharmacist or a medical practitioner with appropriate knowledge and skills should perform the check. The use of systematic checklists is helpful in preventing errors (White et al, 2010; Goldspiel et al, 2015).


All dosage and administration rate-related calculations should be independently verified (Polovich et al, 2014; Neuss et al, 2017). While computerised systems may incorporate medication order safety checks, this does not negate the need for independent manual double checks (Goldspiel et al, 2015).


The five “P”s should be followed to successfully verify a cancer therapy medication order (British Oncology Pharmacy Association, 2013):

  1. Patient details and dosing variables
  2. Prescription/medication order
  3. Protocol and scheduling
  4. Prescribed medication, dose calculations and administration
  5. Patient organ function and laboratory blood tests

The following should be checked to successfully verify the cancer therapy against the medication order (Cancer Institute NSW, 2016):

  1. Correct patient
  2. Correct drug
  3. Correct dose
  4. Correct route
  5. Correct time

At the point of administration, the nurse or practitioner administering the chemotherapy must document that the previous checking process has been completed. At least two individuals in the presence of the patient must verify the identity of the patient using at least three approved patient identifiers; e.g. patient name (family and given names), date of birth, address, medical record number or individual healthcare identifier (Australian Commission on Safety and Quality in Health Care, 2012).


The performance of the above checks must be verified by signing and dating the chemotherapy medication order by both persons (either manually or electronically). This documentation should be in a standardised format.


The patient or carer should have an opportunity to check the medication against information provided and to ask questions about the treatment (Goldspiel et al, 2015). Information must be verified and checked against the medication order and the medication as detailed in Table 14 and Table 15 (White et al, 2010; Neuss et al, 2017; Goldspiel et al, 2015).

  • Clinical_question:What is the procedure for the Nurse when verifying cancer therapy and related medication prior to administration?#Practice_point_1
  • The verification process must be documented in an up-to-date local procedure which outlines the individual systematic checks that nurses are required to undertake when verifying cancer medication orders and the medication prior to administration.

The checking process must not occur until the pharmacist’s verification process has been completed. The checking process must include a verification of the medication order AND a check that the medication to be administered is that prescribed on the order and intended to be administered by the prescriber (Australian Commission on Safety and Quality in Health Care, 2012).


The medication order and chemotherapy, targeted therapy and related medications must be checked at the point of administration by two registered nurses with the appropriate training and skills (Goldspiel et al, 2015; Neuss et al, 2017; White et al, 2010). The checking process by the two nurses should occur independently. Where a second nurse is not available then a pharmacist or a medical practitioner with appropriate knowledge and skills should perform the check. The use of systematic checklists is helpful in preventing errors (White et al, 2010; Goldspiel et al, 2015).


All dosage and administration rate-related calculations should be independently verified (Polovich et al, 2014; Neuss et al, 2017). While computerised systems may incorporate medication order safety checks, this does not negate the need for independent manual double checks (Goldspiel et al, 2015).


The five “P”s should be followed to successfully verify a cancer therapy medication order (British Oncology Pharmacy Association, 2013):

  1. Patient details and dosing variables
  2. Prescription/medication order
  3. Protocol and scheduling
  4. Prescribed medication, dose calculations and administration
  5. Patient organ function and laboratory blood tests

The following should be checked to successfully verify the cancer therapy against the medication order (Cancer Institute NSW, 2016):

  1. Correct patient
  2. Correct drug
  3. Correct dose
  4. Correct route
  5. Correct time

At the point of administration, the nurse or practitioner administering the chemotherapy must document that the previous checking process has been completed. At least two individuals in the presence of the patient must verify the identity of the patient using at least three approved patient identifiers; e.g. patient name (family and given names), date of birth, address, medical record number or individual healthcare identifier (Australian Commission on Safety and Quality in Health Care, 2012).


The performance of the above checks must be verified by signing and dating the chemotherapy medication order by both persons (either manually or electronically). This documentation should be in a standardised format.


The patient or carer should have an opportunity to check the medication against information provided and to ask questions about the treatment (Goldspiel et al, 2015). Information must be verified and checked against the medication order and the medication as detailed in Table 14 and Table 15 (White et al, 2010; Neuss et al, 2017; Goldspiel et al, 2015).

  • Consensus based recommendation
Practice pointQuestion mark transparent.png

Patients and caregivers can play a valuable role in error prevention in the administration checking process. Explaining the checking process and what is being administered while encouraging patients to let nursing staff know if they observe anything different from the routine administration process can help identify potential errors. This needs to be balanced by the patient’s willingness and capability to support this role and provide input (Schwappach and Wernli, 2010).


Additional considerations for home administration

  • Administration of cancer treatments closer to home for people with cancer from rural and remote locations is currently being implemented in some Australian states, with verification processes supported through remote telehealth supervision (Sabesan et al, 2012; Clinical Oncology Society of Australia, 2015; SA Cancer Clinical Network Steering Committee, 2010). The governance and safety of this process must be carefully considered before implementation and balanced against the risk and benefits to the patient.
  • Administration of parenteral therapy in a patient’s home is increasingly becoming a service option in some states. Nursing staff involved in the administration of cancer therapy in the home should ensure that procedures for administration are followed that maximise patient safety and minimise the risk of errors (Evans et al, 2016).
  • Administration and checking processes may need adaptation in both these circumstances to support safe, local provision of care. It is beyond the scope of these guidelines to address the process changes that may be needed to provide these services and to address specific requirements that may apply to parenteral or oral cancer therapy administered by nursing staff in the home.
  • Clinical_question:What is the procedure for the Nurse when verifying cancer therapy and related medication prior to administration?#Practice_point_2
  • Patients and caregivers can play a valuable role in error prevention in the administration checking process. Explaining the checking process and what is being administered while encouraging patients to let nursing staff know if they observe anything different from the routine administration process can help identify potential errors. This needs to be balanced by the patient’s willingness and capability to support this role and provide input (Schwappach and Wernli, 2010).

Additional considerations for home administration

  • Administration of cancer treatments closer to home for people with cancer from rural and remote locations is currently being implemented in some Australian states, with verification processes supported through remote telehealth supervision (Sabesan et al, 2012; Clinical Oncology Society of Australia, 2015; SA Cancer Clinical Network Steering Committee, 2010). The governance and safety of this process must be carefully considered before implementation and balanced against the risk and benefits to the patient.
  • Administration of parenteral therapy in a patient’s home is increasingly becoming a service option in some states. Nursing staff involved in the administration of cancer therapy in the home should ensure that procedures for administration are followed that maximise patient safety and minimise the risk of errors (Evans et al, 2016).
  • Administration and checking processes may need adaptation in both these circumstances to support safe, local provision of care. It is beyond the scope of these guidelines to address the process changes that may be needed to provide these services and to address specific requirements that may apply to parenteral or oral cancer therapy administered by nursing staff in the home.
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How should chemotherapy be safely administered via different routes?

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The chemotherapy, targeted therapy and related medications must be checked at the point of administration by two registered nurses with the appropriate training and skills.

  • All dosage and administration rate-related calculations should be independently verified (White et al, 2010a; White et al, 2010b).

At least one staff member with current, age appropriate training in basic life support should be present during chemotherapy administration (Neuss et al, 2017; Belderson and Billett, 2017).


Only healthcare professionals who have obtained competence in the administration of cancer therapy by the specific administration route should administer cancer therapy via that route.


Cancer therapy should be administered in an area that is equipped to manage any reasonably foreseeable adverse events that may be associated with the medication or route of administration.


Local occupational health and safety workplace guidelines must be followed when handling hazardous medications (NIOSH, 2014; Clinical Oncology Society of Australia and Cancer Pharmacists Group of Australia, 2013).


Policies and procedures for safe medication administration, management of extravasation and emergency procedure protocols must be followed when administering cancer therapy (Polovich et al, 2014; Goldspiel et al, 2015a).


All administrations, observations and actions related to the patient during administration must be documented in the patient’s healthcare records including vital signs, adverse events and patient reported concerns (Polovich et al, 2014). The entry must be made at the time and point of delivery of patient care and be signed and dated.


Nursing staff involved in the administration of therapy in the home should ensure that appropriate procedures are in place to manage any complications and be able to access medical assistance and medications for the management of an adverse event (Evans et al, 2016). Procedures must maximise patient safety and minimise the risk of errors.

  • Clinical_question:How should chemotherapy be safely administered via different routes?#Practice_point_1
  • The chemotherapy, targeted therapy and related medications must be checked at the point of administration by two registered nurses with the appropriate training and skills.
  • All dosage and administration rate-related calculations should be independently verified (White et al, 2010a; White et al, 2010b).

At least one staff member with current, age appropriate training in basic life support should be present during chemotherapy administration (Neuss et al, 2017; Belderson and Billett, 2017).


Only healthcare professionals who have obtained competence in the administration of cancer therapy by the specific administration route should administer cancer therapy via that route.


Cancer therapy should be administered in an area that is equipped to manage any reasonably foreseeable adverse events that may be associated with the medication or route of administration.


Local occupational health and safety workplace guidelines must be followed when handling hazardous medications (NIOSH, 2014; Clinical Oncology Society of Australia and Cancer Pharmacists Group of Australia, 2013).


Policies and procedures for safe medication administration, management of extravasation and emergency procedure protocols must be followed when administering cancer therapy (Polovich et al, 2014; Goldspiel et al, 2015a).


All administrations, observations and actions related to the patient during administration must be documented in the patient’s healthcare records including vital signs, adverse events and patient reported concerns (Polovich et al, 2014). The entry must be made at the time and point of delivery of patient care and be signed and dated.


Nursing staff involved in the administration of therapy in the home should ensure that appropriate procedures are in place to manage any complications and be able to access medical assistance and medications for the management of an adverse event (Evans et al, 2016). Procedures must maximise patient safety and minimise the risk of errors.

  • Consensus based recommendation
Practice pointQuestion mark transparent.png

Administration of cancer treatments closer to home for people with cancer from rural and remote locations is currently being implemented in some Australian states (Sabesan et al, 2012; Clinical Oncology Society of Australia, 2015; SA Cancer Clinical Network Steering Committee, 2010). Under these service models nursing staff should ensure that procedures for administration are followed that maximise patient safety and minimise the risk of errors.


Preparations for parenteral administration must be checked for leaks, precipitation or any other visual signs of problems with the solution. Seek advice from the providing Pharmacist if any concerns or if advice is required.

  • Clinical_question:How should chemotherapy be safely administered via different routes?#Practice_point_2
  • Administration of cancer treatments closer to home for people with cancer from rural and remote locations is currently being implemented in some Australian states (Sabesan et al, 2012; Clinical Oncology Society of Australia, 2015; SA Cancer Clinical Network Steering Committee, 2010). Under these service models nursing staff should ensure that procedures for administration are followed that maximise patient safety and minimise the risk of errors.

Preparations for parenteral administration must be checked for leaks, precipitation or any other visual signs of problems with the solution. Seek advice from the providing Pharmacist if any concerns or if advice is required.

  • Good practice point

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What actions should be performed post-administration of cancer therapy to maximise safety?

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Nursing staff must ensure that all medications required post-administration of the cancer therapy are prescribed and administered according to the protocol and treatment plan (e.g. mesna, folinic acid, intravenous fluids). Requirements may differ according to whether the patient is receiving treatment as an inpatient or day patient.


After administration the nurse must ensure that cytotoxic chemotherapy precautions are observed when handling patient waste. The period of time can vary depending on the route of administration, dose and half-life. Generally precautions should be observed for 48 to 72 hours following parental administration or up to 7 days following oral therapy. These times may be longer according to the protocol or local policy.


Prior to discharge from hospital the nurse should ensure that the patient has the following:

  • Written information on the treatment administered including expected side effects, precautions to be taken and what to do in the case of an adverse effect (e.g. uncontrolled nausea and vomiting, a febrile episode or diarrhoea).
  • Arrangements made for laboratory tests and other tests relevant to the disease and treatment.
  • An appointment for medical review and the next cycle of treatment.
  • The name and phone number of a healthcare professional who is available as a 24 hour contact for advice and emergencies (e.g. on-call practitioner, emergency department).

The nurse should ensure in conjunction with the pharmacist that arrangements are in place for the supply of all required discharge and take home medications e.g. antiemetics, anti-diarrhoeals, colony stimulating factors.

Written and verbal information should be provided by the pharmacist on the medication including instructions on how and when the medication should be taken, expected side effects, precautions to be taken and what to do in the event of an adverse effect.


All post-administration care and actions must be documented in the patient’s healthcare record including care of the patient during and after administration of chemotherapy, discharge medication and the education and information provided to the patient.

  • Clinical_question:What actions should be performed post-administration of cancer therapy to maximise safety?#Practice_point_1
  • Nursing staff must ensure that all medications required post-administration of the cancer therapy are prescribed and administered according to the protocol and treatment plan (e.g. mesna, folinic acid, intravenous fluids). Requirements may differ according to whether the patient is receiving treatment as an inpatient or day patient.

After administration the nurse must ensure that cytotoxic chemotherapy precautions are observed when handling patient waste. The period of time can vary depending on the route of administration, dose and half-life. Generally precautions should be observed for 48 to 72 hours following parental administration or up to 7 days following oral therapy. These times may be longer according to the protocol or local policy.


Prior to discharge from hospital the nurse should ensure that the patient has the following:

  • Written information on the treatment administered including expected side effects, precautions to be taken and what to do in the case of an adverse effect (e.g. uncontrolled nausea and vomiting, a febrile episode or diarrhoea).
  • Arrangements made for laboratory tests and other tests relevant to the disease and treatment.
  • An appointment for medical review and the next cycle of treatment.
  • The name and phone number of a healthcare professional who is available as a 24 hour contact for advice and emergencies (e.g. on-call practitioner, emergency department).

The nurse should ensure in conjunction with the pharmacist that arrangements are in place for the supply of all required discharge and take home medications e.g. antiemetics, anti-diarrhoeals, colony stimulating factors.

Written and verbal information should be provided by the pharmacist on the medication including instructions on how and when the medication should be taken, expected side effects, precautions to be taken and what to do in the event of an adverse effect.


All post-administration care and actions must be documented in the patient’s healthcare record including care of the patient during and after administration of chemotherapy, discharge medication and the education and information provided to the patient.

  • Consensus based recommendation

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