Vol. 6 Issue 22
Chemotherapy Drug Administration Dangers
The more physicians order oral chemotherapy drugs for patients, the more nurses need to be aware of safety precautions
Chemotherapy once was strictly under the domain of the oncology department but not anymore. With its supplemental uses have come safety concerns for nurses administering the drug to patients throughout the hospital setting.
As a clinical nurse specialist in the oncology program at Elmhurst (IL) Memorial Healthcare (EMHC), my duties involve facilitating a task force to annually review the chemotherapy administration policy and make appropriate practice recommendations.
Some of the questions nurses must ask about chemotherapy administration include: Could I have administered a dose of oral chemotherapy to a patient and not been aware I did so? Have I cared for a patient today who has received chemotherapy in the past 48 hours? And if so, did I take any of the special precautions required when caring for the patient?
At EMHC we recently identified challenges in chemotherapy administration that we had to address in a meaningful way. Our impetus for this change process was the frequency with which oral chemotherapy drugs are ordered for non-malignant conditions and our concern for staff and patient safety.
Oral Administration Challenges
One challenge is the administration of oral chemotherapy. Several chemotherapy drugs are now used to treat benign conditions. Two examples include oral methotrexate, which is administered for rheumatoid arthritis, and hydroxyurea for some blood dyscrasias.
The Oncology Nursing Society (ONS) guidelines are not clear about who can administer oral chemotherapy drugs for benign conditions. This creates a difficult situation. After all, the patients administer their own drugs when at home.
We did an audit and found that during a 6-month period of time, more than 600 doses of oral chemotherapy agents were administered at our institution. Our task force realized we needed to address this issue. We understood that it would not be feasible to have a chemotherapy certified nurse administer these drugs on a daily basis.
In addition to reviewing current practice at local institutions, our task force examined recommendations from ONS, the American Society of Clinical Oncology and the American Society of Health System Pharmacists (ASHP). We found that everyone was struggling with the same issue. At that point we realized we needed to educate the staff on how to safely administer these drugs and care for these patients.1
The first step taken was to appropriately label the chemotherapy drugs. OSHA and ASHP stipulate that all hazardous drugs be labeled with a warning label.2 Also, the EMHC pharmacy implemented pre-packing of the single dose and labeling all oral chemotherapy.
The second step involved educating the staff regarding safe-handling techniques during administration. These techniques protect the staff from the powder or dust that may be produced from capsules or tablets of hazardous drugs.
We also developed a self-learning module that instructs staff how to administer these drugs. The module discusses the use of appropriate gloves when opening the medication package and the proper disposal of the gloves and packaging once the drug is administered.
The medication package, gloves and medication cup are disposed of in a re-sealable plastic bag labeled: "Caution chemotherapy drug: observe safety precautions for handling and administration." This re-sealable bag is then placed into an appropriately labeled chemotherapy waste container. In addition, if oral chemotherapy needs to be crushed or mixed, it is done in an appropriate biologic safety cabinet.2
All staff will complete this self-learning module on a yearly basis. In addition, these principles will be discussed during RN orientations.2
Post-Chemo Patient Care
Our second challenge was care of the individual after receiving chemotherapy. Today, chemotherapy is given in more locations than the outpatient ambulatory setting or the dedicated oncology unit. In the OR, for example, chemotherapy is being used for bladder instillation or for vitrectomies. Chemotherapy is being used for sclerosing of some chest tubes and for regional therapy, such as chemoembolization in the interventional radiology suite.
Patients also come to the ambulatory setting for chemotherapy; however, their care is provided on a skilled nursing unit. If you are one of these nurses, do you know what precautions you need to take? Post-administration precautions are necessary, as most chemotherapy drugs and their metabolites are excreted.
In identifying staff providing care for patients following chemotherapy, our task force realized that any clinical staff may be exposed to chemotherapy. We developed a self-learning module that instructs the staff on the necessary precautions. All clinical staff will complete this module on a yearly basis. In addition, these principles will be discussed during nurse orientations.2
The certified chemotherapy nurse is still responsible for the administration and symptom management for parenteral and oral chemotherapy for malignant conditions. However, as more target therapies and additional indications for current chemotherapy agents are developed, everyone needs education for safe practice. Knowledge regarding the medication and proper administration and handling is prudent practice for any healthcare provider.2
1. Griffin, E. (2003). Safety consideration and safe handling of oral chemotherapy agents. Clinical Journal of Oncology Nursing, 6(suppl.7), 25-29.
2. Belcher, C., et al. (2003). Oncology Nursing Society: Safe handling of hazardous drugs. Pittsburgh: ONS Publishing Division.
American Society of Health-System Pharmacists. (2002, Sept. 1). ASHP guidelines on preventing medication errors with antineoplastic agents. American Journal of Health-System Pharmacy, 59(17), 1648-1668.
Oncology Nursing Society. (2001). Chemotherapy and biotherapy: Guidelines and recommendations for practice. (p. 226). Pittsburgh: Author.
Mona Kasper is clinical nurse specialist in oncology, Elmhurst (IL) Memorial Healthcare.
Post Chemotherapy Administration Safety Precautions
Oncology Services at Elmhurst (IL) Memorial Hospital (EMHC) has developed a self-learning module for nurses caring for patients following chemotherapy that includes the following safety precautions:
Chemotherapy precautions are in place for 48 hours post-administration of chemotherapy drug.
Utilize personal protective equipment (gowns, gloves) when handling body fluids.
Wear a face shield if splashing is possible (i.e., emptying a Foley catheter).
Encourage men to sit to void to reduce splashing.
Encourage the use of toilets, not urinals or bedpans, so excreta can be disposed of immediately.
Protect the skin of incontinent patients. After cleansing, apply a moisture barrier to the perineal and perirectal skin.
Flush the toilet with the lid down to help avoid aerolization. If your institution does not have toilets with lids, flush toilet once.
If linens become contaminated during this time period, follow your institution's policy for disposal. (At EMHC, such linens are treated as if they are contaminated with hazardous drugs or infectious waste. Therefore, contaminated linen is placed in a plastic bag, and then placed in a linen bag before it is sent to the laundry.)
Discard disposable contaminated items in an appropriately labeled chemotherapy waste container. Examples of such items include pads, diapers, urinals, bedpans, measuring devices, Foley catheters and drainage bags.
Post sign over bed reading "Chemotherapy Precautions" with start and stop times to alert all individuals caring for the patient.