An audit of compliance with national/local guidelines staff involved in intrathecal chemotherapy

Abstract

Vinca alkaloids, ordinarily administered intravenously (IV), if administered via intrathecal chemotherapy (ITC) almost certainly causes fatal myoencephalopathy. This audit measured adherence to national and Trust guidelines regarding safe prescription, dispensing, issuing, transporting and administration of ITC. The objective was to assess whether only appropriately trained staff on the medical, pharmacy and nursing registers were involved at every stage of ITC delivery. It also sought to recommend changes for better practise. Data on staff involved was obtained from prescription sheets in patient notes and pharmacy copies. Additionally departmental registers and training certification forms were scrutinized. In total 11 patients received between them 59 ITC prescriptions. Only 83.1% of prescriptions were filed and completed. 10.2% were not filed whereas 6.7% were incompletely filled. Nevertheless whenever a staff name was filled in prescriptions, 100% were on the register. The registers show that, apart from 1 new doctor who had been in post less than a year but who had received appropriate training in this Trust, all registered staff had had annual competence reviews. Commendably, all 17 ITC prescriptions which were administered on the same day as an IV prescription, 2 of which were vinca alkaloids, were only issued from pharmacy after receiving proof that the IV prescription had been infused, demonstrating best practise. The audit demonstrates better filing and documentation is imperative so a complete paper trail is available if mishaps happen. The audit recommends patient involvement in pre-ITC safety checks, auditing prescription filing, and increased awareness during ITC training of complete documentation.