Inpatient Oral Chemotherapy Administration Process Developed to Comply With Safety Standards

Inpatient Oral Chemotherapy Administration Process Developed to Comply With Safety Standards
Inpatient Oral Chemotherapy Administration Process Developed to Comply With Safety Standards

SAN ANTONIO, Tex.–Instituting a Chemotherapy Safety Committee and developing an administration process successfully standardized the inpatient oral chemotherapy administration process, according to a presentation at the ONS 41st Annual Congress.1

Because the American Society of Clinical Oncology (ASCO) and Oncology Nursing Society (ONS) recommend safety standards that include the management of oral chemotherapy to improve patient outcomes, Spartanburg Regional Healthcare System (SRHS) in Spartanburg, South Carolina, created a Chemotherapy Safety Committee to review a limited set of oral chemotherapy to identify areas of improvement.

“Our goal was to standardize the consenting, ordering, and documenting for oral chemotherapy to comply with ASCO/ONS Chemotherapy Administration standards for inpatient oral chemotherapy administration,” said Patricia Hegedus, MBA, BSN, RN, OCN, director for clinical oncology operations at Bon Secours Health System, who previously worked at SRHS Gibbs Cancer Center and Research Institute.

A subcommittee was designated to review the current process for oral chemotherapy administration by comparing their process with other community and National Cancer Institute (NCI)-designated hospitals and conducting a literature review.

After reviewing mandated hazard drug requirements by NIOSH and USP 800, the team ultimately expanded the focus from oral chemotherapy agents to all hazardous drugs to include nononcology use of antineoplastic agents such as cyclophosphamide and methotrexate.

Several controls were implemented to improve identification, patient education, and safety for all oral hazardous drugs. Annual comprehensive nursing education related to hazardous drug management was developed and nurses, pharmacy, transport, and housekeeping staff are now required to complete annual competencies.

“The oral chemotherapy process has empowered our bedside nurses to provide a safe environment for the patients and staff,” oncology nurse Catherine Jenkins, BSN, RN, concluded.


1. Hegedus P, Jenkins C. Developing an inpatient oral chemotherapy administration process. Oral presentation at: 2016 Oncology Nursing Society Annual Congress; April 28-May 1, 2016; San Antonio, TX.
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