Department of Pharmacy Policies & Procedures

Number: 5:10

Effective Date: May, 1990

Revisions: 4/96; 4/99; 8/99; 12/04; 5/07; 10/08; 9/09

Approval: October, 1999

Subject: CHEMOTHERAPY ORDERS

A. POLICY

The pharmacy prepares all cancer chemotherapy medications for administration in the hospital. There is a satellite in the chemotherapy infusion center to prepare all chemotherapy for administration to outpatients.

B. PROCEDURE FOR INPATIENTS

The copy of the physician's order (yellow NCR, FAX or electronically) is sent from the nursing unit to the pharmacy.

The order is entered into the computer or verified from the electronic medical record and projected hang times are assigned each unit of chemotherapy.

All chemotherapy orders of the same drug are numbered sequentially for preparing and administering.

All chemotherapy order entry is checked by a second pharmacist against the physician's order. The order copy is initialed by the entering pharmacist and the checking pharmacist.

All chemotherapy labels are run with the IV labels every 8 hours. New orders requiring drug between delivery times will have labels printed at the time of order entry.

All chemotherapy products which are physically stable will be prepared routinely with each I.V. delivery. Any drugs which present logistical or physical stability problems will be prepared on a "demand" basis.

All products which are cytotoxic are assembled and prepared in the vertical flow hood in accordance to procedure 8:11.

The preparing pharmacist records dilution and dosage information on the back of the product label. This information and all drug vials relating to the preparation of the product are retained until checked by a second pharmacist. The second pharmacist verifies the accuracy of the preparation as to correct drug selection and dosage calculation, and initials the product label next to the preparer's initials.

Tamper tell seal(s) are affixed to any I.V. bag. A "Chemotherapy" auxillary warning label is attached to the container.

If the chemotherapy is prepared for I.V. push, the solution is drawn into the syringe and the needle is removed. Filling syringes to their full capacity will be avoided. Prepared syringes sent to the nursing units for I.V. push administration should never be more than 3/4 full.  A luer-lock syringe cap is placed on the end of the syringe. The syringe assembly is then taped to a disposable tray.

All labeling of cytotoxic products will be placed directly on the container (i.e., I.V. bag, bottle, or syringe.) Special warning labels such as the IV Push only labels will also be attached directly to the container.

All cytotoxic agents are placed in a zip-sealed plastic bag which is labeled as Chemotherapy.

All chemotherapy products will be spiked and primed with the appropriate tubing prior to being dispensed by the pharmacy.  See Spiking Procedure.

Chemotherapy products MUST be picked up at the window of the pharmacy.

C. PROCEDURE FOR OUTPATIENTS

A copy of the physician’s order (FAX or NCR copy) is sent to the chemotherapy infusion center satellite pharmacy from the clinic or chemo treatment room.

A pharmacist or pharmacy student verifies the order and enters the order into the computer.

Labels are matched with the order and the chemotherapy medication is prepared.

All products which are cytotoxic are assembled and prepared in the vertical flow hood in accordance to procedure 8:11.

All chemotherapy is prepared by a trained individual assigned to work in the satellite.

The individual who prepared the chemotherapy records the amount of the drug used on the order and signs the order.

A second pharmacist verifies that the flow rate, total volume, expiration date, and amount used is correct and co-signs the order.  In the event that there is not a second pharmacist available to double check the order, the preparing pharmacist records the lot number of the drug on the order form indicating that they have rechecked their work.

If the chemotherapy is prepared for I.V. Push, the solution is drawn into the syringe and labeled so that the fluid level and the graduations on the syringes are still clearly visible.

All chemotherapy products will be spiked and primed with the appropriate tubing prior to being dispensed by the pharmacy.  See Spiking Procedure.

The finished products are placed in the window of the pharmacy in safe containers, where the nurse picks them up for the infusion center.

Products needed in other location must be delivered via a transport individual.  All products that may be tubed, will be tubed to the area needed.