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Chemotherapy Processes: Informed Consent, Ordering, Verification, Administration, Documentation, and Patient/Family Education (6.1.1)

Chemotherapy Processes: Informed Consent, Ordering, Verification, Administration, Documentation, and Patient/Family Education (6.1.1) - Policies, Clinical, UW Health Clinical, Medications and Pharmacy

6.1.1


UW HEALTH CLINICAL POLICY 1
Policy Title: Chemotherapy Processes: Informed Consent, Ordering, Verification,
Administration, Documentation, and Patient/Family Education
Policy Number: 6.1.1
Category: UW Health
Type: Ambulatory and Inpatient
Effective Date: July 13, 2017

I. PURPOSE

To ensure safe and competent ordering and administration of chemotherapy to adult and pediatric patients
in the inpatient, ambulatory, and home care settings.

II. DEFINITIONS

A. Beacon: The Epic software program used to create standardized order sets for recurrent cyclic therapies
such as chemotherapy regimens to treat malignancies.
B. Beacon Protocol: A set of chemotherapy orders (standard of care or research) built in Beacon which has
been approved by the Chemotherapy Council or Pediatric Disease Oriented Team (DOT) and can be
applied to a patient.
C. Beacon Treatment Plans: A Beacon Protocol that has been applied to a patient and customized as needed,
based on patient criteria.
D. Central venous access device (CVAD): According to Nursing Patient Care policy #1.56 AP, Central Venous
Access Device Use, Maintenance and Removal, a CVAD is a catheter inserted into a peripheral or centrally
located vein with the tip residing in the superior or inferior vena cava.
E. Chemotherapy Competent Nurse: A registered nurse (RN) credentialed in compliance with Nursing Patient
Care policy #10.28 AP, Chemotherapy Competence for Nurses.
F. Chemotherapy Competent for Certain Agents Nurse: A registered nurse (RN) credentialed in compliance
with Nursing Patient Care policy #10.28 AP, Chemotherapy Competence for Nurses.
G. Chemotherapy Competent Pharmacist: A pharmacist (RPh) who has passed the required chemotherapy
competencies.
H. Chemotherapy Competent Fellow: Fellows who have been approved to sign chemotherapy orders by their
fellowship program director.
I. Chemotherapy Competent Physician: An attending who has privileges in chemotherapy.
J. Competent for Chemotherapy Order Verification Nurse: A registered nurse (RN) credentialed in compliance
with Nursing Patient Care policy #10.28 AP, Chemotherapy Competence for Nurses.
K. Patient Specific Regimen (non-research): A Beacon Treatment plan built for a specific patient after approval
from the Chemotherapy Review Council for adult patients and Tumor Board for pediatric patients.
L. Pre-printed physician orders (PPO): A set of predefined chemotherapy orders (standard of care or research)
created for approved chemotherapy regimens that are intended to be printed on paper and used on multiple
patients.
M. Privileged Advanced Practice Provider (APP): An APP who has been granted “NP/PA Chemotherapy
Ordering” privileges.
N. Standard of Care (non-research core regimen): chemotherapy protocols approved by the Chemotherapy
Council for adult patients or a Pediatric Disease Oriented Team (DOT) for pediatric patients.

III. POLICY ELEMENTS

All chemotherapy regardless of indication will be ordered, verified, and administered using safe, evidence-
based practice to optimize patient outcomes.

Refer to related resource “Medications Defined as Chemotherapy” for a list of drugs the UW Health defines
as chemotherapy.

IV. CHEMOTHERAPY FOR ONCOLOGIC INDICATIONS

A. Informed Consent



UW HEALTH CLINICAL POLICY 2
Policy Title: Chemotherapy Processes: Informed Consent, Ordering, Verification, Administration, Documentation and
Patient/Family Education
Policy Number: 6.1.1

i. Prior to the first dose of chemotherapy and prior to any new chemotherapy regimen, an informed
consent according to policy UWHC policy #4.17, Informed Consent must be completed
ii. In the rare circumstance where the patient is unable to give consent and person making decisions
on behalf of the patient is not present, a verbal consent over the telephone is acceptable, according
to UWHC policy #4.17, Informed Consent, unless the consent is for a research study, then verbal
consent cannot be used.
iii. If the patient is participating in a research study, the protocol specific informed consent will serve as
the informed consent if all chemotherapy medications are addressed, including possible side
effects. In the event the protocol specific consent defers to standard of care, then standard of care
consent will also be obtained.
iv. Standard of care consent is the responsibility of the medical team. Research study consent is the
responsibility of appropriate research personnel.
v. The chemotherapy competent attending or fellow will perform the following:
a. Review consent and sign with patient, parent or authorized decision maker and obtain
written assent for research patients seven years and older.
b. Complete dictation or enter a note in Health Link to include the following:
1. Diagnosis and nature of illness
2. Explanation of the recommended treatment to be performed
3. The purpose of the treatment
4. Side effects of the treatment
5. Inherent risk, potential hazards and benefits of the treatment
6. Viable alternatives to the treatment or procedure, including the risks and benefits
of each alternatives
7. Consequences of no treatment or an alternative treatment
vi. The chemotherapy competent RN or RPh will provide patient with appropriate verbal information
and written education materials.
vii. The chemotherapy competent RN will verify consent was obtained.
B. Ordering
i. General Principles
a. All chemotherapy orders must comply with UWHC policy #8.16, Patient Care Orders.
b. Intrathecal chemotherapy must be ordered according to UW Health Clinical Policy #6.1.3,
Intrathecal Chemotherapy Ordering, Administration, and Documentation.
c. Authorized prescribers
1. Non-research chemotherapy orders may only be signed by:
A. Chemotherapy competent physician and fellows
B. Privileged APP
i. May only sign adult chemotherapy in cycle two and beyond of
a treatment plan
ii. Pediatrics only: may sign chemotherapy in cycle two and
beyond of a treatment plan and cycle one for subsequent
phases of a protocol
2. Research chemotherapy orders may only be signed by a research protocol
specific authorized prescriber.
d. Verbal orders are only allowed for holding or stopping chemotherapy after an adverse
drug event.
e. Chemotherapy Order Entry Cutoff for Inpatient and Outpatient Areas
1. Except in the case of an emergent need (as outline in related reference
“Emergent Chemotherapy”), chemotherapy orders are provided to the RPh by
1800 Monday through Friday and 1400 on Saturdays, Sundays and all UW



UW HEALTH CLINICAL POLICY 3
Policy Title: Chemotherapy Processes: Informed Consent, Ordering, Verification, Administration, Documentation and
Patient/Family Education
Policy Number: 6.1.1

Health designated holidays. If orders are provided after these times, they will be
processed by the RPh the following day.
2. Appropriate labs and other diagnostics and procedures (e.g. central venous
access device placement) should be completed prior to the cutoff times to allow
for clinical order verification by the RPh and medication administration
scheduling.
ii. Chemotherapy Order Development
a. All Beacon protocols are developed and maintained by the Oncology Health Link protocol
analysts in collaboration with the submitting Disease Oriented Team of physicians, the
Chemotherapy Review Council (adults), clinical nursing, pharmacy staff and research staff
as appropriate.
b. All research study PPOs must be developed and maintained according to the Oncology
Research Paper Orders Template and associated guidance document.
c. The approval of adult standard of care protocols, including research protocols, are
reviewed by the Disease Oriented Team (DOT) of physicians or designated research
coordinator, respectively, every three years. Supporting documentation of the review is
retained by the Beacon Build Team of Health Link Orders and by the DOT for PPOs.
d. The review of orders must compare orders against the protocol or other reference
documents(s) by a minimum of one chemotherapy competent physician, one
chemotherapy competent RPh, and one chemotherapy competent RN prior to use. Each
person examines the content for accuracy, clarity and error prone elements. Once the
multidisciplinary review has been completed, orders may be used.
iii. Beacon Treatment Plans contain the following information, as applicable
a. Reference information
b. Treatment Plan Summary which includes the disease for which the protocol is approved
c. Height (cm)
d. Weight (kg)
e. Body Surface Area (BSA)
f. Treatment date(s)
g. Laboratory tests and relevant treatment conditions to be met prior to beginning
chemotherapy
h. Nursing assessment and monitoring parameters
i. Hydration
j. Pre-medication, including antiemetics
k. Emergency medications
l. Treatment /drug generic names, actual dose, dose per calculation, total dose, route, drug
sequence, rate and quantity to be dispensed
m. Treatment medications administration instructions
n. Dose modifications if applicable (indicate course/cycle/week/day/number as applicable)
are documented in a “Oncology Treatment Modification Note”
o. Version identifier and expected review date
p. Adults only: “Treatment Tolerance Notes”
iv. Paper Orders for Treatment Plans
a. Paper orders should only be used when electronic ordering is not possible (e.g. downtime,
research), and contain the same elements required in a Beacon treatment plan (see
section “IV. B. iii.”). In addition, each page of the paper orders requires the ordering
provider’s printed name, signature, date and time.
b. Paper orders must be handwritten for a single patient on current approved PPO.
1. If a PPO is not available, follow the Beacon protocol as a template for writing
orders on approved order forms.



UW HEALTH CLINICAL POLICY 4
Policy Title: Chemotherapy Processes: Informed Consent, Ordering, Verification, Administration, Documentation and
Patient/Family Education
Policy Number: 6.1.1

c. Pharmacists will transcribe all medication and fluid orders originating on paper into Health
Link.
d. Provider or nurse will transcribe all non-medication and non-fluid orders into Health Link.
v. Chemotherapy Orders in Procedure Areas
a. For the purpose of this policy, procedure areas may include but are not limited to
University Hospital (UH) and American Family Children’s Hospital (AFCH) Operating
Rooms, Urology Clinic, and Interventional Radiology.
b. Orders are submitted by an approved Order Set or PPO.
C. Order Verification
i. At a minimum, one chemotherapy competent RN and one chemotherapy competent RPh
independently verify the treatment plan orders. Table 1 outlines the elements of the order the must
be verified and the person(s) responsible for such verification.
a. In procedure areas: one chemotherapy competent for certain agents RN or competent for
chemotherapy order verification RN and one RPh independently verify all of the orders.
ii. The RPh document completion of order verification with an electronic signature when he/she
verifies the medication in Health Link.
iii. The RNs documents completion of order verification with an electronic signature when he/she
verifies the medication in Health Link and writes a “Treatment Plan Verification Note”.
a. Pediatrics only: the administering RN also verifies that the date and dose are written on
the roadmap.
iv. When there is a difference of 10% or greater between the dose written by the provider and the
dose calculated using the current BSA or weight, the prescribing or covering attending physician,
fellow or APP is notified.
v. Research Study
a. RN Research Coordinators who are chemotherapy competent RNs will verify research
treatment plan orders. This verification includes release of the orders where applicable
and documentation of the Treatment Verification note in Health Link.
b. Research Coordinators who are not chemotherapy competent RNs verify all research
related orders and document a Treatment Verification note. Then a chemotherapy
competent RN will verify the treatment plan as prescribed in section “IV.C., including
documentation of their verification.
c. The chemotherapy competent RN treating the patient will perform the “RN Verify” function
as appropriate prior to drug administration.

Table 1. Elements Verified by the RPh and RN during the Order Verification Process
ELEMENT OF ORDER RPh 1 RN1 RN 2
(paper orders only)
Patient Name X X X
MR Number X X X
Ht, Wt, BSA X X X
Approved regimen for disease (core,
patient specific or research)
X X
Consent X
Pertinent Lab Values X X
Compare to Protocol or Road Map if
applicable , including interval between
cycles
X X
X
Drug X X X
Dose X X X
Route X X X
Solution and volume if specified X X X
Start dates and times X X X
Stop dates and times X X X



UW HEALTH CLINICAL POLICY 5
Policy Title: Chemotherapy Processes: Informed Consent, Ordering, Verification, Administration, Documentation and
Patient/Family Education
Policy Number: 6.1.1

Infusion Time X X X
Appropriate Ancillary Medications
(hypersensitivity prophylaxis and
antiemetics)
X X
X
Appropriate Hydration X X X
Take Home Medications X X
Appropriate follow up labs and
appointments X X


D. Prepared Product Verification
i. Done in accordance with UWHC policy #8.33, High Alert Medication Administration.
ii. All chemotherapy is checked by one RPh and two chemotherapy competent RNs or by two
chemotherapy competent for certain agents RNs. What each person is responsible for verifying is
outline in Table 2.
iii. RNs document their verification in the electronic medication administration record in accordance
with UWHC policy #8.33, High Alert Medication Administration.
iv. Pediatrics only: the administering RN also verifies the date and dose are written on the roadmap.
Table 2. Product Verification and Role of the Chemotherapy Competent RPh and Chemotherapy
Competent RN/Chemotherapy Competent for Certain Agents RN
PRODUCT VERIFICATION RPh RN 1
(administering)
RN 2
(witness)
Patient Name X X X
MR Number X X X
Drug Dose X X X
Volume and Solution X X X
Filter and tubing (if applicable) X X X
Infusion Time/Rate (if applicable) X X
Route X X X
Expiration (if applicable) X X

V. CHEMOTHERAPY FOR NON-ONCOLOGIC INDICATIONS

A. Informed Consent
i. Informed consent is not required when prescribing chemotherapy for a non-oncologic indication
except for IV cyclophosphamide. Prior to the first dose of cyclophosphamide, an informed consent
according to UWHC policy #4.17, Informed Consent must be completed.
B. Ordering
i. General Principles
a. All chemotherapy orders must comply with UWHC policy #8.16, Patient Care Orders.
b. Authorized Prescribers
1. For non-research chemotherapy orders, only attending physicians, fellows or
Privileged APPs working within their scope of practice may order chemotherapy
for non-oncologic indications.
2. Research chemotherapy orders may only be signed by a research protocol
specific authorized prescriber.
c. Verbal orders are only allowed for
1. Holding or stopping chemotherapy after an adverse drug event
2. Induction therapy for solid organ transplants
ii. Chemotherapy Orders in Procedure Areas
a. For the purpose of this policy, procedure areas may include but are not limited to
University Hospital (UH) and American Family Children’s Hospital (AFCH) Operating
Rooms, Urology Clinic, and Interventional Radiology.



UW HEALTH CLINICAL POLICY 6
Policy Title: Chemotherapy Processes: Informed Consent, Ordering, Verification, Administration, Documentation and
Patient/Family Education
Policy Number: 6.1.1

b. Orders are submitted by an approved Order Set or PPO.
C. Order Verification
i. Order verification is completed by one RPh and one RN.
ii. The RPh documents completion of order verification with an electronic signature when he verifies
the medication in Health Link. If an electronic MAR is not available, documentation is completed
with a progress note.
iii. The RN documents completion of order verification with an electronic signature when he verifies
the medication in Health Link. If an electronic MAR is not available, documentation is completed
with a progress note.
iv. When there is a difference of 10% or greater between the dose written by the provider and the
dose calculated using the current BSA or weight, the prescribing or covering attending physician,
fellow or APP is notified.
D. Prepared Product Verification
i. Done in accordance with UWHC policy #8.33, High Alert Medication Administration.
ii. All chemotherapy is checked by one RPh and two RNs. What each person is responsible for
verifying is outlined in Table 2.
iii. RNs document their verification in the electronic medication administration record in accordance
with UWHC policy #8.33, High Alert Medication Administration.

VI. ADMINISTRATION

A. General Administration Guidelines
i. Chemotherapy ordered for the treatment of an oncologic indication must be administered by a
chemotherapy certified RN.
ii. Chemotherapy ordered for the treatment of non-oncologic indications may be administered by any
RN. Staff should use the pharmacy and nursing staff on B6/6 or UW Health Carbone Cancer
Center (for adults) and P4 (for pediatrics) as a resource for administration questions.
iii. When administering intravenous (IV) infusions of chemotherapy, follow policies UW Health clinical
policy # 6.1.8, Administration of Intravenous Medications, UWHC policy #8.33, High Alert
Medication Administration, and Nursing Patient Care policy #1.24, Alaris System. The Alaris
System is not used when
a. Administering vesicants via a peripheral venous catheter (PIV)
b. The Alaris System is not available
iv. If chemotherapy needs to be administered to an adult inpatient for an oncologic indication on a unit
that does not have a chemotherapy competent RN staffed on it, follow the guidelines in related
resource “Chemotherapy Checklist for Off Unit Administration.”
v. Prior to administering the chemotherapy, two independent double checks are completed as
outlined in UWHC policy #8.33, High Alert Medications and overall infusion set up, correct
hydration (solution, volume, rate) and correct IV tubing set-up, is verified.
vi. Drugs should be administered in sequence according to study, protocol, or specific provider order.
vii. If giving more than one drug, flush line with compatible solution between drugs.
viii. It is recommended that short term continuous infusion chemotherapy (less than 24 hours) is
infused through a secondary line.
ix. Vesicants infusing over a 1 hour period or longer may only be administered as an infusion through
a CVAD.
x. Check for blood return before drug administration, whenever compromised vein integrity is
suspected (swelling, discoloration, leakage, or complaints of discomfort), and at the end of drug
administration.
a. Verify blood return by attaching a syringe to the needless connector or IV tubing port
closest to the patient or via gravity by removing the bag from the pump, lowering it below
the patient’s IV site and watch for blood return.
xi. Instruct patient to report signs of leakage, swelling, discoloration, complaints of pain, or pain in
chest/shoulder area throughout chemotherapy infusion
xii. Consult a pharmacist if there is any question about compatibility of chemotherapy with other IV
solutions/products



UW HEALTH CLINICAL POLICY 7
Policy Title: Chemotherapy Processes: Informed Consent, Ordering, Verification, Administration, Documentation and
Patient/Family Education
Policy Number: 6.1.1

xiii. Refer to Clinical Practice Guideline: Guidelines for the Management of Extravasation of
Antineoplastic Agents is extravasation is suspected
xiv. Prior to administering chemotherapy, instruct the patient/family on expected and potential side-
effects and to inform the nurse of any symptoms experienced during the infusion
xv. Follow UWHC policy #8.89, Preventing Occupational Exposure to Hazardous Drugs for all policies
and procedures dealing with safe handling of hazardous drugs
B. Via Central Venous Access Device (CVAD)
i. The following are CVADs and may be used for infusion of vesicant and non-vesicant
chemotherapy: Hickman, Groshong, Broviac catheters, implanted ports, and Peripherally Inserted
Central Catheters (PICC). Chemotherapy should not be administered via an apheresis or dialysis
catheter.
ii. Midline catheters are not considered central catheters. Refer to section “VI.C.” on administering
chemotherapy via a peripheral catheter.
iii. Patients with CVADs that are placed at outside facilities will have placement verified by RN
comprehensive assessment that includes:
a. Minimum Recommendation: physical assessment and patency as described in Nursing
departmental polices #1.56 AP, Central Vascular Access Device Use, Maintenance and
Removal.
b. Strong recommendation: obtain original radiographic placement report, or film
documenting tip location at the time the line was placed, or by obtaining a chest x-ray
which shows proper tip placement.
iv. Verify blood return prior to administering any chemotherapy via a CVADs.
a. If unable to verify blood return refer to Nursing Patient Care policy #1.56 AP, Central
Vascular Access Device Use, Maintenance, and Removal.
b. CVAD may be used once integrity has been established (verified by blood return or
successful dye study), or via provider order.
v. Implanted Venous Ports: secure needle in a way that allows visualization of the site. Maintain site
according to Nursing Patient Care policy #1.56 AP, Central Venous Access Device Use,
Maintenance and Removal.
vi. At the conclusion of therapy, flush CVAD according to Drug Use Guidelines: Flushing Guidelines
for Venous Access Devices.
C. Via Peripheral Intravenous Catheter (PIV)
i. Preparation/vein selection for PIV
a. Avoid using an existing IV site that is more than 24 hours old
b. It is preferable to select a large, smooth, and pliable vein in the forearm
c. Lower extremities may not be used for chemotherapy
d. It is preferable to avoid the following when placing an PIV:
1. Areas of flexion
2. Limbs with compromised circulation
3. Limbs with axillary lymph node dissection
4. Recent sites of IVs or venipunctures. Always select a site above previous
venipuncture sites to avoid leakage or extravasation
5. Bruised, inflamed or sclerosed vein
6. Small, fragile, tortuous veins
7. Areas that have been irradiated
8. Extremities with decreased sensation or paresthesia
e. When inserting an PIV, needle size and peripheral catheter type (butterfly or angio-
catheter) is based upon:
1. Rate and length of infusion
2. The product to be infused
3. The size of the patient’s veins
4. Cognitive function/mobility of the patient
5. Select the smallest gauge and shortest length catheter to accommodate the
prescribed therapy
f. Insert PIV per Nursing Patient Care policy #1.23 AP, Continuous Peripheral Intravenous
Therapy.
g. The venipuncture site and the surrounding area of the limb should be taped/dressed in a
manner that will allow for visualization of the site



UW HEALTH CLINICAL POLICY 8
Policy Title: Chemotherapy Processes: Informed Consent, Ordering, Verification, Administration, Documentation and
Patient/Family Education
Policy Number: 6.1.1

h. If you have any doubts about the integrity of the PIV site during chemotherapy
administration, (swelling, leaking, discoloration, loss of blood return, complaints of
discomfort) restart the PIV in another site
ii. Unless specified by protocol:
a. Give the vesicant drug(s) first when venous integrity is at its maximum
b. Give the irritant drug(s) last as they may cause venous spasm or discomfort, which could
be misconstrued as signs/symptoms of extravasation
iii. For pediatrics:
a. Routine administration of chemotherapy via a PIV is not recommended
1. PIV administration may occur following discussion between the attending and
treating RN
D. Intravenous (IV) Push (Injecting drug directly into the vein)
i. This practice is strongly discouraged.
ii. Only non-vesicants/non-irritants may be administered in this manner through either a PIV or CVAD.
To determine if drug is a vesicant or irritant, refer to Intravenous Administration of Formulary
Medications—Adult—Inpatient/Ambulatory Clinical Practice Guidelines or Intravenous
Administration of Formulary Medications—Neonatal/Pediatrics—Inpatient/Ambulatory Clinical
Practice Guidelines.
iii. See Table 3 for site assessment and patency monitoring.
iv. Flush with a small amount of compatible solution to check venous integrity.
v. Slowly inject the chemotherapy drug.
vi. Flush with compatible solution between drugs and at the conclusion of the treatment.
E. IV Side Arm Pushes (Instilling a drug though the side port of a free flowing IV)
i. All vesicant and non-vesicant agents may be administered in this manner through either a
peripheral or CVAD.
ii. Push chemotherapy slowly though a free-flowing IV at the injection port closest to the patient to
allow for adequate gradual dilution of the drug.
iii. Administer the first milliliter of the drug slowly in order to evaluate for patient reaction.
iv. See Table 3 for site assessment and patency monitoring.
F. IV infusions
i. When administering a vinca alkaloids prepared in a mini bag
a. via a peripheral catheter the chemotherapy must be administered by gravity with the
registered nurse continuously monitoring the site throughout the infusion.
b. via a CVAD may be given via a pump or by gravity.
c. Pediatrics: vinca alkaloids are routinely administered via CVADs. If administering via PIV
refer to section “V.C.” and give via gravity.
ii. See Table 3 for site assessment and patency monitoring. In collaboration with the pharmacist,
contact the physician if rate adjustment is necessary to ensure completion of infusion over
prescribed time, and pharmacist will place an order to indicate this change.

Table 3. Registered Nurse (RN)
IV Side Arm Push/Vinca Alkaloid Mini-bag Infusion
NON-VESICANT
-PIV and CVAD
Site assessment: before infusion and whenever RN
suspects vein/device integrity is compromised.

Blood return: prior to administration, whenever RN
suspects vein/device integrity is compromised, and
at the end of administration.
VESICANT
-PIV and CVAD
Site assessment: constant monitoring throughout
infusion for signs of infiltration (swelling,
discoloration, leakage, patient complaints or
discomfort).

Blood return: prior to administration and every 2-5
mL or whenever RN suspects vein/device integrity is
compromised, and at the end of administration.
IV Infusion
NON-VESICANT Site assessment: before infusion and whenever RN



UW HEALTH CLINICAL POLICY 9
Policy Title: Chemotherapy Processes: Informed Consent, Ordering, Verification, Administration, Documentation and
Patient/Family Education
Policy Number: 6.1.1

-PIV and CVAD suspects vein/device integrity is compromised.

Blood return: prior to, every 8 hours during
infusion, and at the end of infusion.
IRRITANT
-PIV and CVAD
Site assessment: before infusion, every hour and
whenever RN suspects vein/device integrity is
compromised.
Blood return: prior to, every 8 hours during infusion,
and at the end of infusion.
VESICANT
-CVAD*

*NOTE: vesicants cannot be administered as
continuous infusion through a peripheral venous
catheter
Site assessment: before infusion, every hour and
whenever RN suspects vein/device integrity is
compromised.
Blood return: prior to, every 8 hours during infusion,
and at the end of the infusion.

G. Intramuscular (IM) and Subcutaneous Administration
i. General principles:
a. Chemotherapy to be administered by the IM or subcutaneous route must be taken to the
patient's bedside separately from chemotherapy that is administered by any other route.
Administration of IM or subcutaneous chemotherapy must be completed prior to bringing
any other chemotherapy agent to the patient's bedside
ii. IM Administration
a. Use proper needle size to ensure the medication is delivered into the muscle and not
subcutaneous tissue, especially obese patients
b. Insert needle at 90°
c. Avoid massaging the site
iii. Subcutaneous Administration
a. Avoid umbilicus and scars
b. Rotate injection sites if multiple injections are needed
c. Do not use subcutaneous catheter device (Insuflon)
H. Oral Chemotherapy
i. Oral chemotherapy ordered for an oncologic indication must be administered by a chemotherapy
competent RN
ii. Oral chemotherapy ordered for a non-oncologic indication can be given by any RN per UWHC
policy #8.33, High Alert Medication Administration and UWHC policy #8.89, Preventing
Occupational Exposure to Hazardous Drugs.
iii. Consult the pharmacist to determine if the medication can be crushed, or if the capsule can be
emptied.
iv. Consult the pharmacist to determine if the medication should or should not be taken with food, and
determine appropriate solids or liquids used for administration.
v. Do not leave oral chemotherapy or protective agents (i.e. mesna, leucovorin) at the bedside.
Observe the patient while he/she swallows the medication.
I. Intrathecal Administration: Refer to UW Health clinical policy #6.1.3, Intrathecal (IT) Chemotherapy
Ordering, Administration and Documentation.
J. Intrathecal Reservoir Administration: Refer to Nursing Patient Care policy #10.14, Access to Intrathecal
Reservoirs and Administration of Medications Including Chemotherapy Agents.
K. Intraperitoneal Administration: Refer to Nursing Patient Care policy #1.30, Use of the Implanted
Intraperitoneal (IP) System.
L. Hepatic Arterial Infusion Pump: may only be managed by a Chemotherapy Competent RN.

VII. DOCUMENTATION

A. Document administration of all medications and IV hydration in the electronic MAR.
i. Pediatrics only: Treatment medications are also documented on the roadmap for pediatric patients.
B. For ambulatory patients in University Hospital Infusion Center, UW Carbone Cancer Clinics and AFCH Day
Treatment, document the stop time of all IV administered medications in the electronic MAR
C. Vascular access device information is documented in the patient's medical record and must include:



UW HEALTH CLINICAL POLICY 10
Policy Title: Chemotherapy Processes: Informed Consent, Ordering, Verification, Administration, Documentation and
Patient/Family Education
Policy Number: 6.1.1

i. Type of access
ii. If applicable, catheter or needle gauge, length, date/time/location of placement and date/time of
removal
iii. Patency
iv. Site assessment
v. Dressing condition
vi. Flush solution and volume/dose
D. Any adverse event (i.e. extravasation and actual/potential medication errors) is documented in the patient's
record and via internal incident reporting system in accordance with UWH administrative policy #4.22, UW
Health Event Reporting. Documentation includes facts describing the situation and what occurred, and
interventions initiated and their effectiveness
E. Adverse drug reactions
i. Inform pharmacist
ii. Document via internal incident reporting system in accordance with UWH administrative policy
#4.22, UW Health Event Reporting.
iii. Adults only: add a “Treatment Tolerance” note in the Beacon Treatment Plan
iv. Documentation includes facts describing the situation and what occurred and interventions initiated
and their effectiveness
F. Extravasation management: refer to UWHC Guidelines for the Management of Extravasation of
Chemotherapy Agents – Pediatric/Adult – Inpatient/Ambulatory Clinical Practice Guideline
G. Vital Signs and other nursing assessments/monitoring are documented in the patient’s medical record.
H. Education
i. All patient and family education to be in compliance with UW Health clinical policy #3.5.4, Patient
and Family Education.
ii. Document in the Patient Teaching activity in Health Link
iii. Refer to the appropriate Health Facts for You, Inpatient Service Specific Interdisciplinary Plans of
Care (IPOC), Patient Education Guidebooks, or for pediatric patients/families: “Newly Diagnosed
Children with Cancer”, for content

VIII. FORMS

UWH #40002317 Inpatient Chemotherapy Order Form
UWH #1280071 Physician’s Orders

IX. COORDINATION

Author: Oncology Clinical Nurse Specialist
Senior Management Sponsor: SVP/Chief Nursing Officer
Reviewers: Oncology Care Practice Committee, Chemotherapy Council, Director of Clinical Research
Approval committees: Pharmacy and Therapeutics Committee; UW Health Clinical Policy Committee,
Medical Board
UW Health Clinical Policy Committee Approval: May 15, 2017

UW Health is a cohesive, united and integrated academic medical enterprise comprised of several entities.
This policy applies to facilities and programs operated by the University of Wisconsin Hospitals and Clinics
and the University of Wisconsin Medical Foundation, Inc., and to clinical facilities and programs
administered by the University of Wisconsin School of Medicine and Public Health. Each entity is
responsible for enforcement of this policy in relation to the facilities and programs that it operates.

X. APPROVAL

Peter Newcomer, MD
Chief Clinical Officer

J.Scott McMurray, MD
Chair, UW Health Clinical Policy Committee

XI. REFERENCES



UW HEALTH CLINICAL POLICY 11
Policy Title: Chemotherapy Processes: Informed Consent, Ordering, Verification, Administration, Documentation and
Patient/Family Education
Policy Number: 6.1.1


-Oncology Nursing Society's Chemotherapy and Biotherapy Guidelines and Recommendations for Practice,
4rd Edition (2014)
-Document (To be posted on U-Connect): "Governance Process for Build and Maintenance of Oncology
Protocols in Health Link"
-Cancer Center Policy on U-Connect: "Chemotherapy Review Council Description & Submission & Review
Process for Core Chemotherapy Regimens "
-Cancer Center Policy on U-Connect: "Chemotherapy Review Council Submission for Individualized,
Patient-Specific Chemotherapy Regimens "
UWHC policy #4.17 Informed Consent
UWHC policy #4.22, Event Reporting
UWHC policy #8.16, Patient Care Orders
UW Health clinical policy #6.1.3, Intrathecal (IT) Chemotherapy Ordering, Administration and Documentation
UW Health clinical policy #6.1.8, Administration of Intravenous Medications
UWHC policy #8.33, High Alert Medication Administration
UWHC policy #8.89, Preventing Non-Therapeutic Exposure to Hazardous Drugs
Nursing Patient Care policy #10.28 AP, Chemotherapy Competence for Nurses (Adult and Pediatric)
Nursing Patient Care policy #1.24 AP, Alaris System (Adult & Pediatric)
Nursing Patient Care policy #1.56 AP, Central Venous Access Device Use, Maintenance and Removal
(Adult & Pediatric)
Nursing Patient Care policy #10.14 AP, Access to Intrathecal Reservoirs and Administration of Medications
Including Chemotherapy Agents (Adult & Pediatric)
Nursing Patient Care policy #1.30, Use of the Implanted Intraperitoneal (IP) System for Chemotherapy
Administration
UW Health clinical policy #3.5.4, Patient and Family Education
Nursing Patient Care policy #6.29, Processing Patient Care Orders
Flushing/Locking of Venous Access Devices – Adult/Pediatric – Inpatient/Ambulatory Clinical Practice
Guideline
Infusion Nursing Standards of Practice (2016)
UWHC Guidelines for the Management of Extravasation of Chemotherapeutic Agents – Adult/Pediatric –
Inpatient/Ambulatory Clinical Practice Guideline

XII. REVIEW DETAILS
Version: Revision
Last Full Review: July 13, 2017
Next Revision Due: July 2020
Formerly Known as: Hospital Administrative policy #8.59