Cancer therapy and associated treatment can be administered by several routes including oral, intravenous infusion, intravenous bolus, intraventricular, subcutaneous and intradermal. Many of these routes require administration by an appropriately credentialed cancer nurse or an appropriately informed patient, where the medication is being self-administered. Administration via more specialised routes such as intrathecal and intraperitoneal may require a medical practitioner with specialist or surgical experience. There are a number of safety checks required to ensure safe administration of cancer therapy.
Policies, procedures and equipment for safe administration and handling of cancer therapy must be easily accessible, understood and adhered to by all nurses involved in the administration of cancer therapy.
Administering cancer treatment in an area that is suitable for the process and equipped to manage any reasonably foreseeable adverse events associated with the medication or route of administration is an essential part of medication safety. The environment should be free from unnecessary noise and activity. The patient conditions (e.g. seating, lighting) should enable the patient to comfortably receive therapy and encourage easy communication with nursing staff.
The availability of local procedures, medical assistance and medications to manage any complications that may arise during administration ensure adverse events are managed appropriately and in a timely manner.
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.
(White et al, 2010a) ;(White et al, 2010b) ;(Neuss et al, 2017) ;(Belderson and Billett, 2017) ;(NIOSH, 2014) ;(Clinical Oncology Society of Australia and Cancer Pharmacists Group of Australia, 2013) ;(Polovich et al, 2014) ;(Goldspiel et al, 2015a) ;(Evans et al, 2016)
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.
Table 16: Administration of cancer therapy by specified routes
| ADMINISTRATION VIA THE INTRAVENOUS ROUTE
|ADMINISTRATION VIA THE INTRAMUSCULAR AND SUBCUTANEOUS ROUTE
| ADMINISTRATION VIA THE INTRATHECAL ROUTE
Note: Further recommendations on intrathecal cancer therapy are provided under the General Information section of these guidelines.
| ADMINISTRATION VIA THE ORAL ROUTE
Note: Further recommendations on oral cancer therapy are provided under the General Information section of these guidelines.
- Polovich M, Olsen M and LeFevre KB. Chemotherapy and Biotherapy Guidelines and Recommendations for Practice (Fourth Edition). Pittsburg: Oncology Nursing Society; 2014.
- Neuss MN, Gilmore TR, Belderson KM, Billett AL, Conti-Kalchik T, Harvet BE, et al. 2016 Updated American Society of Clinical Oncology/Oncology Nursing Society Chemotherapy Administration Safety Standards, Including Standards for Pediatric Oncology. Oncol Nurs Forum 2017 Jan 6;44(1):31-43 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/28067033.
- Carrington C, Stone L, Koczwara B, Searle C, Siderov J, Stevenson B, et al. The Clinical Oncological Society of Australia (COSA) guidelines for the safe prescribing, dispensing and administration of cancer chemotherapy. Asia Pac J Clin Oncol 2010 Sep;6(3):220-37 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/20887505.
- Cancer Institute NSW. eviQ Cancer Treatments Online. [homepage on the internet]; [cited 2016 Sep]. Available from: https://www.eviq.org.au.
- Gilbar PJ, Seger AC. Accidental intrathecal administration of bortezomib: preventing fatalities. Asia Pac J Clin Oncol 2013 Sep;9(3):290-1 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/23176407.
- Goldspiel BR, DeChristoforo R, Hoffman JM. Preventing chemotherapy errors: updating guidelines to meet new challenges. Am J Health Syst Pharm 2015 Apr 15;72(8):668-9 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/25825190.
- Schulmeister L. Preventing chemotherapy errors. Oncologist 2006 May;11(5):463-8 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/16720846.
- Department of Health UK (Chief Medical Officer). Health Service Circular HSC 2008/001: Updated national guidance on the safe administration of intrathecal chemotherapy.; 2008 [cited 2016 Sep] Available from: http://webarchive.nationalarchives.gov.uk/20130107105354/http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_086844.pdf.
- White RE, Bourrier V, Dobish R, Easty AC. Improving the safety of ambulatory intravenous chemotherapy in Canada. Canadian Journal of Hospital Pharmacy 2010;63(1):80-1.
- White RE, Trbovich PL, Easty AC, Savage P, Trip K, Hyland S. Checking it twice: an evaluation of checklists for detecting medication errors at the bedside using a chemotherapy model. Qual Saf Health Care 2010 Dec;19(6):562-7 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/20724398.
- Belderson KM, Billett AL. Chemotherapy safety standards: A pediatric perspective. Pediatr Blood Cancer 2017 Jun;64(6) Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/28306217.
- NIOSH. By Connor TH, MacKenzie BA, DeBord DG, Trout DB, O’Callaghan JP. NIOSH list of antineoplastic and other hazardous drugs in healthcare settings 2014. Publication No. 2014-138 (Supersedes 2012-150). Cincinnati, OH: US Department of Health and Human Services (DHHS), Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health (NIOSH); 2014 [cited 2016 Sep] Available from: http://www.cdc.gov/niosh/docs/2014-138/pdfs/2014-138.pdf.
- Clinical Oncology Society of Australia and Cancer Pharmacists Group of Australia. Position Statement: Safe handling of monoclonal antibodies in healthcare settings.; 2013 [cited 2016 Sep] Available from: https://www.cosa.org.au/media/173517/cosa-cpg-handling-mabs-position-statement_-november-2013_final.pdf.
- Goldspiel B, Hoffman JM, Griffith NL, Goodin S, DeChristoforo R, Montello CM, et al. ASHP guidelines on preventing medication errors with chemotherapy and biotherapy. Am J Health Syst Pharm 2015 Apr 15;72(8):e6-e35 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/25825193.
- Evans JM, Qiu M, MacKinnon M, Green E, Peterson K, Kaizer L. A multi-method review of home-based chemotherapy. Eur J Cancer Care (Engl) 2016 Sep;25(5):883-902 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/26545409.
- Sabesan S, Larkins S, Evans R, Varma S, Andrews A, Beuttner P, et al. Telemedicine for rural cancer care in North Queensland: bringing cancer care home. Aust J Rural Health 2012 Oct;20(5):259-64 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/22998200.
- COSA Teleoncology Guidelines Working Group. Clinical practice guidelines for teleoncology. [homepage on the internet] Sydney: Cancer Council Australia; Available from: http://wiki.cancer.org.au/australia/COSA:Teleoncology.
- South Australian Cancer Clinical Network Steering Committee. Standards for Chemotherapy Services in South Australia.; 2010 [cited 2017 May] Available from: http://www.sahealth.sa.gov.au/wps/wcm/connect/89ec480045a68ae78fdeaf9f9859b7b1/Standards+for+Chemotherapy+Services+in+South+Australia+January+2011.pdf?MOD=AJPERES&CACHEID=89ec480045a68ae78fdeaf9f9859b7b1.
- Cancer Institute NSW. eviQ Cancer Education Online. [homepage on the internet]; Available from: https://education.eviq.org.au/.
- The National Cancer Nursing Education Project (EdCaN). A national professional development framework for cancer nursing.; 2009 Available from: http://edcan.org.au/assets/edcan/files/docs/EdCanWeb_2nded.pdf.
- Fluorouracil: dosing errors with infusion pumps. Prescrire Int 2014 Oct;23(153):242 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/25969854.
- Institute for Safe Medication Practices. ISMP Safety alert: Fluorouracil error ends tragically, but application of lessons learned will save lives. [homepage on the internet]; 2007 Sep 20 Available from: http://www.ismp.org/newsletters/acutecare/articles/20070920.asp.
- Australian Commission on Safety and Quality in Health Care. National Safety and Quality Health Service (NSQHS) Standard 6: Clinical Handover. [homepage on the internet]; 2007 [cited 2016 Sep]. Available from: https://www.safetyandquality.gov.au/our-work/clinical-communications/clinical-handover/.
- Schulmeister L. Preventing vincristine administration errors: Does evidence support minibag infusions? Clin J Oncol Nurs 2006 Apr;10(2):271-3 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/16708708.
- Noble DJ, Donaldson LJ. The quest to eliminate intrathecal vincristine errors: a 40-year journey. Qual Saf Health Care 2010 Aug;19(4):323-6 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/20211962.
- Marliot G, Le Rhun E, Sakji I, Bonneterre J, Cazin JL. Securing the circuit of intrathecally administered cancer drugs: example of a collective approach. J Oncol Pharm Pract 2011 Sep;17(3):252-9 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/20525750.
- Lester J. Safe handling and administration considerations of oral anticancer agents in the clinical and home setting. Clin J Oncol Nurs 2012 Dec;16(6):E192-7 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/23178361.
- Carrington C. Oral targeted therapy for cancer. Aust Prescr 2015 Oct;38(5):171-6 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/26648656.
- Carrington C. Safe use of oral cytotoxic medicines. Australian Prescriber 2013;36(1):9-12.
- NHS National Patient Safety Agency UK. Rapid Response Report (NPSA/2008/RRR001). Risks of incorrect dosing of oral anti-cancer medicines. [homepage on the internet]; 2008 Jan 22 [cited 2016 Sep]. Available from: http://www.nrls.npsa.nhs.uk/resources/?entryid45=59880.
- Society of Hospital Pharmacists of Australia. Don't Rush to Crush. 2nd edition; 2015.