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Administration of the wrong drug or dose is likely to be fatal.
The following policy has been written to comply with the current national recommendations issued by the Scottish Government “Guidance for the Safe Delivery of Systemic Anti-Cancer Therapy (SACT)” CEL 30 (2012) July 2012 and the current NHSGG&C “Policy for the Prescribing, Supply and Administration of Cytotoxic Intrathecal Systemic Anti-Cancer Therapy.” [Staffnet link]
Children who require intrathecal chemotherapy.
In the United Kingdom there have been fatal errors associated with the administration of intrathecal drugs. An intrathecal drug is an agent given by intrathecal injection as part of a chemotherapy regimen ie methotrexate, cytarabine or hydrocortisone.
Administration of the wrong drug or dose is likely to be fatal. The following policy has been written to comply with the current national recommendations issued by the Scottish Government “Guidance for the Safe Delivery of Systemic Anti-Cancer Therapy (SACT)” CEL 30 (2012) July 2012 and the current NHSGG&C “Policy for the Prescribing, Supply and Administration of Cytotoxic Intrathecal Systemic Anti-Cancer Therapy.” [Staffnet link]
Adherence to this policy aims to minimise the risk to patients receiving intrathecal chemotherapy within the Royal Hospital for Children, Glasgow. It is expected that this policy will be read in conjunction with the NHSGG&C policy.
2.1 Procedure for Performing a Diagnostic Lumbar Puncture & Administration of Intrathecal Chemotherapy (RHC-HAEM-ONC-012)
2.2 Policy & Guidelines for Preparation, Prescribing & Administration of Cytotoxic Agents for Children under the Care of Schiehallion (RHC-HAEM-ONC-014)
2.3 Intrathecal Chemotherapy Assessment (RHC-HAEM-ONC-015)
2.4 Spillage Procedures for Chemotherapy (RHC-HAEM-ONC-005)
2.5 NHSGG&C Policy for the Prescribing, Supply and Administration of Cytotoxic Intrathecal Systemic Anti-Cancer Therapy [Staffnet link]
3.1 The following staff must be aware of this policy and understand its impact on practice:
3.2 Register of Designated Personnel:
3.3 Education & Training:
3. 4 Professional Responsibility:
4.1 Intrathecal Chemotherapy Prescription Form.
4.2 Access to Adult & Paediatric Intrathecal Register
4.3 Personal Protective Equipment (PPE) –personal protective equipment/PPE should be worn for administration of all SACT. This includes:
PPE should also be worn when disposing of unused SACT in a purple sharps box which should be securely closed as per hospital policy in a yellow clinical waste bin held within the locked waste cupboard.
5.1 Prescribing:
5.2 Preparation & Dispensing:
5.3 Labelling, Packaging & Storage in the Pharmacy:
5.4 Issue of Drugs from Pharmacy:
5.5 Timing of Issue from the Pharmacy:
NB: Any out-patient having a bone marrow aspirate MUST be given any scheduled intravenous bolus chemotherapy prior to theatre. Inpatients MUST be scheduled to have intravenous bolus chemotherapy on a different day from the bone marrow aspirate.
5.6 Patient Review:
5.7 Administration of Drug(s):
This SOP will be reviewed every two years.
This procedure is subject to external audit under the Intrathecal Cytotoxic Chemotherapy Administration checklist contained within the CEL 2009 (21) guidance. Audits are normally performed every 3 years.
There are no exceptions to this SOP and deviations are not acceptable.
For further information contact:
Dr Nicholas Heaney
Royal Hospital for Children, Glasgow
Tel: 0141 201 0000, Page 8116 9.
Safe Administration of Intrathecal Cytotoxic Chemotherapy – CEL 21 (www.staffnet.ggc.scot.nhs.uk/Acute/Regional%20Services/Specialist%20Oncology%20Services/Pages/SpecialistOncologyChemotherapyServices.aspx - under CEL Guidelines)
Safe and Secure Handling of Medicines in Hospital Wards, Theatres and Departments
(www.ggcprescribing.org.uk/medicines-policies) - under Section 6.2 - Safe and Secure Handling of Medicines (Acute Division)
Policy for the Prescribing, Supply and Administration of Cytotoxic Intrathecal Chemotherapy
(www.staffnet.ggc.scot.nhs.uk/Acute/Regional%20Services/Specialist%20Oncology%20Services/Pages/SpecialistOncologyChemotherapyServices.aspx - under NHSGGC Guidelines)
Last reviewed: 28 August 2023
Next review: 31 August 2025
Author(s): Dr Nick Heaney
Version: 9
Approved By: Schiehallion Clinical Governance Group
Document Id: RHC-HAEM-ONC-013