Purpose:
The purpose is to provide standard guidelines for the prescribing and provision of chemotherapy.
Applicable Locations:
Ambulatory Care Chemotherapy
Central Inpatient IV Room
Clinical Care Pediatrics
Policy:
A. Chemotherapy is defined as any agent with antineoplastic properties, with the exception of oral
antineoplastics that are taken chronically.
B. Chemotherapy is only dispensed for administration in a UNC Hospitals and Clinic environment by
the Pharmacy Department pursuant to complete orders written by an authorized prescriber
(Prescriptions for home use are not covered by this policy).
Procedure:
A. All chemotherapy orders must be signed by a UNC Hospitals authorized prescriber prior to
execution of the order.
B. All orders for chemotherapy must be written on a UNC Hospitals chemotherapy order form
approved by the Medical Records Committee. Blank and regimen-specific online forms are
available at
http://www.unch.unc.edu/pharmacy/chemo/protocols_chemo/adultchemofrmBlank.pdf
All patient information needed to assess appropriateness of orders is included on the
chemotherapy order form.
1. Required Information: The indication height, weight, and body surface area must
be included on the chemotherapy order form. If targeted area under the curve
(AUC) is used to calculate a dose of antineoplastic, the patient’s estimated or
actual creatinine clearance is included on the chemotherapy form with the
formula used to estimate clearance.
2. The name and number of active research protocols or the name of the standard
regimen is indicated on the order form. Copies of active research protocols and
their amendments are made available to nursing and pharmacy staff by
prescribers and are kept in the pharmacy and patient care units. If patients are
treated off of active research protocols or standard regimens, supportive
literature is provided and placed in the patient’s medical record. In the absence
of available literature, approval of the Division Chair is required prior to order
execution.
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Category Acute Care: Clinical Care Pharmacy
Name of Policy Chemotherapy Use and Prescribing Guidelines
Date Effective April 1997
Date Last Reviewed August 2004
Reviewing Director Assistant Director of Medical & Surgical Services
4. All antineoplastic doses are specified per unit body surface area, per unit body
weight or AUC when applicable. Modifications of a protocol/standard dose are
specified on the chemotherapy order form. The final dose to be administered is
provided on the chemotherapy form. All orders will use a standard format
including dose/BSA, dose/kg, or AUC/day. In the case of an antineoplastic
administered multiple times on a day, the format is dose/BSA or dose/kg.
5. All pertinent laboratory data for the regimen is available to pharmacy and nursing
and is reviewed prior to order execution.
7. All antineoplastic orders specify the route of administration and infusion time (or
IV push) for intravenous administration.
C. The pharmacist responsible for screening the chemotherapy order and the nurse administering
the chemotherapy confirm the regimen/protocol dose and recalculate the patient dose based on
the parameters written on the order form. The screening pharmacist and the treatment nurse
sign the bottom of the chemotherapy order when final dosage checks and calculations have been
verified.
D. Compatible antineoplastics are physically admixed together if the administration rate and day of
administration are the same. The physician may request an admixture or the pharmacist may at
his/her discretion admix agents with documented physical and chemical compatibility. If a
dilution is not specified on an order, a standard dilution based on known compatibility data will
be used by the pharmacy.
F. Records of chemotherapy ordered and dispensed will be maintained for a period of 2 years then
shredded.
Responsible Unit:
Clinical Care Service Pharmacist
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Category Acute Care: Clinical Care Pharmacy
Name of Policy Chemotherapy Use and Prescribing Guidelines
Date Effective April 1997
Date Last Reviewed August 2004
Reviewing Director Assistant Director of Medical & Surgical Services
Approved By:
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