Towards quality control in cancer chemotherapy

Abstract

Summary A survey of all hospital pharmacies in the former North Western Regional Health Authority has revealed that hospital personnel continue to prepare cytotoxic drugs in suboptimal conditions, despite the widespread introduction of pharmacy cytotoxic reconstitution services. Other concerns include the lack of formal training for medical staff in the administration of these agents and the frequent absence of written procedures for dealing with extravasation and chemotherapy errors.Keywords: audit; delivery of cancer chemotherapy A series of well-publicised accidents in which patients have died as a result of errors in the administration of cytotoxic agents (Sunday Times, 1993;Zaragoza et al., 1995) are a reminder that these drugs remain among the most toxic substances commonly administered.Occupational exposure to cytotoxic drugs has been associated with adverse pregnancy outcomes Selevan et al., 1985;McDonald et al., 1988;Stucker et al., 1990), an excess risk of leukaemia (Skov et al., 1990(Skov et al., , 1992 and case reports of bladder (Levin et al., 1993) and nasopharyngeal carcinoma (Gabriele et al., 1993). An Australian pharmacist recently won industrial compensation when he presented with duodenal cancer after preparing cytotoxic drugs in a faulty biohazard cabinet that had repeatedly failed safety checks (Hudson, 1990;Carden, 1991;Rodriguez and Yap, 1991).Although the absence of robust measures of exposure and the need to ascertain rare outcome events make it difficult to precisely quantify the risk to healthcare personnel, most countries have introduced formal guidelines (Health and Safety Executive, 1983; Pharmaceutical Society Working Party, 1983; OSHA, 1986;Skov, 1993) that aim to reduce staff exposure to antineoplastic drugs to the lowest practicable level. The Joint Council for Clinical Oncology (JCCO) has also recently published a series of recommendations that clarify the responsibilities of medical staff for the prescribing and administration of cancer chemotherapy (Table I) (JCCO, 1994).We now report a regional survey, the aim of which was to describe the delivery of cancer chemotherapy before the dissemination of the JCCO guidelines (JCCO, 1994). Our objectives were to report on current practices relating to the prescribing, preparation and administration of cancer chemotherapy. MethodA postal questionnaire, prepared and piloted in consultation with medical oncologists and hospital pharmacists, was distributed to all hospital pharmacies in the former North Western Regional Health Authority in July 1993. Construction of the questionnaire was informed by a draft of the JCCO (1994) guidelines and previous published guidelines (Health and Safety Executive, 1983; Pharmaceutical Society Working Party, 1983) Pharmacy cytotoxic reconstitution services were available on site in 21 of the 29 units (72%). Of the eight hospitals with no on-site facility, the services of an outside hospital were used in four and drug preparation took place on the ward or outpatient department in the remainder. Eve...

Can We Prevent Cytotoxic Disasters?

“…Several sources have suggested standards for the delivery of cancer chemotherapy in a safe manner, recognizing that it is potentially delivered in a number of hospital and other settings ( Cohen et al , 1996 ; Fischer et al , 1996 ; Woodman et al , 1996 ). The Joint Council for Clinical Oncology in the UK has recommended the following regarding cancer chemotherapy (as summarized by Woodman et al , 1996 ):…”

“…Despite these recommendations, there are a number of hospitals and pharmacies working under suboptimal conditions ( Fischer et al , 1996 ; Woodman et al , 1996 ) Although oncology nurses are usually specifically trained and certified in chemotherapy administration, physicians may not be qualified to administer these agents. It is perhaps one of the most vital aspects of preventing chemotherapy errors that maintenance of competence be made a high priority in any centre that plans to administer chemotherapy.…”