Safer medicines administration – cytotoxic agents

Cytotoxic drugs (sometimes known as antineoplastic) describe a group of medicines that contain chemicals which are toxic to cells, preventing their replication or growth. As well as being used as chemo-therapeutic agents to treat cancer, they are also used to treat long-term conditions such as rheumatoid arthritis and multiple sclerosis.

Once inside the body, their action is not generally tightly targeted, and they can produce side-effects both to the patients and others who become exposed.

Hospice sites have a duty under the Control of Substances Hazardous to Health (COSHH) regulations to risk assess their use of cytotoxic agents and put controls in place to prevent occupational exposure.

How do I know if a prescribed medication is a cytotoxic agent?

Ashtons has produced a poster for the clinic room which clearly displays the names of substances known to contain cytotoxic agents as a reference tool (order code: CYM1).

What should I do if I have a patient who is prescribed a cytotoxic agent?

Hospices must carry out a risk assessment and identify who may be harmed and how.

A useful tool is available on the HSE website.

Particular attention should be paid to trainee staff, and new and expectant mothers. Consideration should also be given to non-medical staff indirectly exposed, such as cleaners and maintenance staff.

Consideration should be made to address the risk these medications may pose to all patients through prescribing error, accidental administration or medicines diversion.

How do I reduce the risk of exposure?

Key points:

1. Drug identification and the communication of risks can be achieved through use of the Ashtons Cytotoxic Poster, and additional endorsement on prescription charts.
2. Have a hospice policy that specifically covers handling cytotoxic agents.
3. Implement specific training on cytotoxic agents during staff/bank staff induction.
4. Ensure that spillages are dealt with promptly.
5. Segregate medication in a trolley, or drug cabinet to a marked ‘cytotoxic’ location.
6. Use adequate Personal Protective Equipment (such as gloves for handling medications). Further guidance on PPE based on the risks identified is available from the HSE toolkit.
7. Ensure staff notification of early pregnancy to ward managers and staff use of PPE.
8. Identify patients with similar names and clearly mark Cytotoxic Medication on the front cover of medication charts.
9. Ensure safety is reviewed for early self-medication programmes where there is an increased risk of error.
10. Reduce prescribing risks due to patient prescription endorsement of cytotoxic and handling risk.

Prescribing risk reduction for methotrexate (a commonly encountered cytotoxic medication)

(a) National Patient Safety Agency document ‘Towards the safer use of oral methotrexate’
(b) Use only one strength for methotrexate prescription and administration (2.5mg) to reduce administration errors.
(c) Specify the day of administration, as methotrexate is administered ONCE weekly.
(d) Ensure that patients are aware of the dose and frequency, and supplied with methotrexate warning cards (order code AHP5940).
(e) Ensure that staff are aware of signs of methotrexate toxicity and the patient is warned to immediately report the onset of any feature of blood disorders (e.g. sore throat, bruising and mouth ulcers), liver toxicity (e.g. nausea, vomiting, abdominal discomfort and dark urine), and respiratory effects (e.g. shortness of breath).
(f) Ensure that patients are adequately monitored (FBC, LFT and U&E) every 1–2 weeks until therapy is stabilised and thereafter every 2–3 months.

How do I respond to cytotoxic spillages and destructions?

Actions should be taken to reduce the risk of cytotoxic spillages, such as the use of disposable injection trays to restrict surface contact.

Sites should use separate dispensing triangles clearly marked and designated for cytotoxic use. For compliance with health and safety regulations, hospices using cytotoxic agents should have a cytotoxic spillage kit. Please contact Customer Services if you require this item.

Cytotoxic medications should be disposed of according to the Health Technical Memorandum on the management and disposal of healthcare waste (HTM 07-01) in purple-lidded bins. These are available from your waste care provider.