Cytotoxic drugs can be prescribed and administered for a variety of conditions.
Cytotoxic medication can affect all cells, but it tends to affect cells that divide rapidly or uncontrollably, particularly:
- cancerous cells
- cells from the gastrointestinal tract
- hair follicles
- early blood cells in the bone marrow.
Cytotoxic agents cannot distinguish between normal and malignant cells, although normal cells have a greater capacity for repair. Cytotoxic drugs act by interfering with cell division, but as this action is not specific to tumour cells, normal cells may also be damaged. Knowledge of the nature of the cell cycle is necessary to understand the action of the cytotoxic medication (see Figure 1).
The cell cycle consists of five phases: G1, S, G2, M and G0:
- G1 - an initial resting phase.
- S - the synthetic phase, during which time the doubling of DNA occurs.
- G2 - a second resting phase, or premitotic.
- M - the process of mitosis, resulting in two identical cells.
- G0 - temporarily removed from the cell cycle, cell will re-enter at a later stage.
Cytotoxic medication works by destroying, damaging or interrupting cellular activity at specific points in the cell cycle.
For health care personnel the potential for exposure exists during tasks such as drug reconstitution, preparation, administration, the disposal of waste medicine and equipment and the disposal of patient bodily fluids and waste.
Important issues in caring for children receiving cytotoxic medication are:
- Safe handling of cytotoxic medication (Rationale 1) and (Rationale 2).
- Managing adverse reactions and complications.
- Supportive care for the child to manage the side effects of cytotoxic drugs (Rationale 3).
All staff involved in handling and administering cytotoxic medication must be familiar and adhere to the Great Ormond Street Hospital (GOSH) policies and guidelines relating to cytotoxic drugs.
These resources are available via the 'Cytotoxic medicines policies and guidelines' GOSHweb intranet page (available internally to GOSH staff) and include the following documents referred to in this guideline:
- Guidelines for the Safe Prescribing, Handling and Administration of Cytotoxic Drugs
- Updated National Guidance on the Safe Administration of Intrathecal Chemotherapy - Dept of Health August 2008
- Policy for Prescribing, Dispensing, Supply and Administration of Intrathecal and Intrareservoir Cytotoxic Injection at GOSH
- Policy for Safe Handling of Hazardous Medicines
- Cytotoxic Medication Training Policy
- Out of Hours Chemotherapy Policy
These guidelines reflect best practice in the Pan London guidelines (2011) (Rationale 4).
All staff involved in the administration of cytotoxic medication must have undergone appropriate training and been registered on the Trust-wide training database of those staff assessed as competent in the administration of cytotoxic medication (Cytotoxic Medication Training Policy).
Under the Hazardous Waste Regulations (2005) cytotoxic and cytostatic medication includes medicinal product possessing any one, or more, of the following hazardous properties:
- H6: Toxic substances and preparations which if they are inhaled or ingested or if they penetrate the skin, may involve serious, acute or chronic health risks.
- H7: Carcinogenic substances and preparations which if they are inhaled or ingested or if they penetrate the skin may induce cancer or increase its incidence.
- H10: Toxic for Reproduction (teratogenic) substances and preparations which if they are inhaled or ingested or if they penetrate the skin may produce or increase the incidence of non heritable adverse effects in the progeny and or the male or female reproductive functions or capacity.
- H11: Mutagenic substances and preparations which if they are inhaled or ingested or if they penetrate the skin may induce hereditary genetic defects or increase their incidence.
Safe handling of cytotoxic and cytostatic medication
Direct exposure to cytotoxic and/or cytostatic drugs can occur during administration or handling, and can be the result of inhalation, ingestion or absorption. The health risk of any procedure involving cytotoxic and/or cytostatic drugs stems from the inherent toxicity of the drug and the extent to which health care workers and patients are exposed.
All staff involved in the handling of cytotoxic drugs should attend a training session on the handling of cytotoxic drugs and on the management of cytotoxic spillages as part of their orientation and yearly update (Rationale 2).
Protective Personal Equipment (PPE) is necessary when handling cytotoxic drugs and cytotoxic waste (Rationale 2).
PPE worn during administration and disposal of cytotoxic medication and when dealing with a cytotoxic spillage should include:
- eye protection
FFP3 masks should be worn during administration and when managing a spillage if there is a risk of spraying, splashing or aerosols.
PPE should be worn by all staff handling patient excreta (urine, vomit, faeces) for seven days after the administration of chemotherapy and includes (Rationale 5):
- plastic apron
Families/caregivers should be advised to wear gloves when handling their child’s excreta (urine, vomit, faeces) for seven days after the administration of chemotherapy (the use of washing up gloves or equivalent should be advised in the home).
Staff who are pregnant or planning to conceive should seek advice from the Occupational Health department and their line manager before handling cytotoxic medication (Rationale 6).
Management of cytotoxic spillages
All cytotoxic spillages should be managed in accordance with the 'Guidelines for the Safe Prescribing, Handling and Administration of Systemic Anti Cancer Treatment Drugs' (Pan London guidelines 2011).
Cytotoxic spillage kits must be available and all staff working in areas where cytotoxic medication is administered must know where the cytotoxic spillage kit is located and how to use it.
Immediate action in the event of a cytotoxic spillage:
- Restrict access to the spillage area.
- Alert other members of staff in the vicinity and inform a senior member of staff.
- If you have been injured or contaminated, another member of staff must deal with the spillage while you receive attention for the injury or contamination following the procedure detailed in Section 13 personal accidents of the 'Guidelines for the Safe Prescribing, Handling and Administration of Cytotoxic Drugs' (Pan London 2011).
- New and expectant mothers should not have direct involvement in the management of a cytotoxic spillage.
- Turn off all fans.
- Open a cytotoxic spill kit.
- If protective clothing has been contaminated during the spillage, remove the contaminated items and put on fresh protective clothing from the spillage kit. Place all contaminated items in the designated cytotoxic waste bin.
- Follow the procedure as outlined in the cytotoxic spill kit.
Any individual who suffers any form of contamination of chemotherapy should ensure an incident form is completed via DATIX and occupational health is informed (Rationale 7).
In order to ensure the safety of staff in the event of a subsequent spillage any used kit must be replaced immediately (replacement kits are obtainable from the Pharmacy department).
Patients receiving infusions of chemotherapy must be cared for in clinical areas where staff have been trained in the management of cytotoxic medication spillages (Rationale 8).
Disposable PPE must be disposed of in a designated cytotoxic waste bag. Visors and glasses are reusable and must be rinsed with warm soapy water, dried and then stored safely in the chemotherapy preparation room.
If there is any cytotoxic residue this needs to be handled as follows:
- In used ampoules and vials: the vial or ampoule must be discarded in a designated cytotoxic sharps bin.
- In syringes: the syringe must be put in a designated cytotoxic waste bag with a hub secured.
- Paper waste which is contaminated with cytotoxic residue following a dry or wet spillage is disposed of by discarding in bin designated for cytotoxic waste.
- Infusion sets once a non-cytotoxic flush has been administered: the entire set must be disposed of in a designated cytotoxic waste bag/bin.
Cytotoxic waste includes:
- All equipment and materials used for cytotoxic spillage.
- ‘Frank’ chemotherapy such as a syringe, infusion set and/or bags of cytotoxic chemotherapy not administered.
- All equipment and materials used to prepare chemotherapy.
- Empty syringes.
Cytotoxic waste should be disposed of using clearly marked cytotoxic waste bins and bags.
Any doses prepared by the Cytotoxic Unit which are not required or have expired must be returned to the Unit for disposal in the designated delivery container. Any expired doses must be returned before a replacement supply is made (Rationale 9).
Safe administration of cytotoxic drugs
Health care professionals involved in all aspects of cytotoxic medication and administration should be adequately trained. This training should be updated annually (Pan London guidelines 2011).
The administration of cytotoxic drugs must be in accordance with the Trust’s Medicine Administration Policy and the Cytotoxic Medicines: Policies and Guidelines ie the Policy for the safe handling of hazardous medicines and the guidelines for the safe prescribing, handling and administration of cytotoxic drugs.
Chemotherapy can be given to patients via various routes, including oral, intravenous, intrathecal, subcutaneous, intramuscular, intraresevoir and topically.
Nursing staff are not permitted to administer intrathecal or intraresevoir chemotherapy (Rationale 10).
Following training and successful assessment of competence, nursing staff administer chemotherapy via all other routes.
Children who receive long term cytotoxic treatment should have a central venous access device (CVAD) inserted (Pan London Guidelines 2011).
Health care professionals administering cytotoxic drugs are first required to be competent in intravenous drugs before they can begin training to administer cytotoxic medication.
Nursing staff administering cytotoxic medicines are responsible for ensuring that all safety parameters, in line with the patient’s treatment plan and protocol guidelines are checked prior to administering cytotoxic medication (Pan London guidelines 2011)(Rationale 11).
Preparation of cytotoxic drugs out of hours
Out of hours is defined as between 5pm and 8.30am on Mondays-Fridays and after 12pm on weekends and Bank Holidays.
Nursing staff involved in preparing cytotoxic medications out of hours must be competent to administer cytotoxic medication and have received additional training in the preparation of cytotoxic medications within a micro isolator cabinet.
Wherever possible, all cytotoxic medication should be initiated, and as much as is feasible, administered within normal working hours (Rationale 13).
Patients may only be commenced on new cytotoxic medication outside Monday to Friday 8.30am-6pm under the circumstances indicated in section 6 (Pan London guidelines 2011) of the guidelines for the safe prescribing, handling and administration of cytotoxic drugs (Rationale 14).
In circumstances where cytotoxic medications are to be prepared out of hours by appropriately prepared nursing staff a record of 'cytotoxic medications prepared after hours' form must be completed and either scanned or a paper copy given to the lead chemotherapy nurse to ensure there is a record of this (Rationale 15). The form can be found in the Out of Hours Chemotherapy Policy (located on the Divisional drive).
Appropriate PPE should be worn:
Collect the child’s health record, treatment protocol and necessary test results appropriate to treatment (Rationale 11).
Ensure a consent form has been completed and signed (Rationale 16).
Ensure that the child has been examined and deemed fit for chemotherapy (Rationale 17)
Inform the child and family that you are preparing to commence treatment and allow time for questions (Rationale 18).
Identify an appropriate designated safe area to prepare chemotherapy. Place a ‘Do Not Enter’ sign on the door (Rationale 4).
Closely follow the instructions for reconstitution of cytotoxic medications within a micro isolator cabinet (located on Lion Ward).
Following reconstitution of the medication, ensure that pharmacy worksheet(s) detailing how to reconstitute the chemotherapy and returned to pharmacy (Rationale 19).
Administration of cytotoxic medications prepared out of hours by nursing staff should be in accordance with the administration guidance contained in this guideline.Staff working within the haematology/oncology setting are expected to be familiar with the Out of Hours Chemotherapy Policy.
Staff administering oral cytotoxic medicines should be assessed as competent to administer cytotoxic medication.
- Appropriate PPE should be worn (Rationale 4):
- plastic apron
- non sterile gloves
- chemical repellent armlets
- Collect the child’s health record, treatment protocol and necessary test results appropriate to treatment (Rationale 16). Ensure a consent form has been completed and signed.
- Ensure that the child has been examined and deemed fit for cytotoxic medication (this must be documented in the child’s medical notes) (Rationale 17).
- Inform the child and family that you are preparing to commence treatment and allow time for questions (where available, a drug information sheet should be provided) (Rationale 18).
- Identify an appropriate designated safe area to prepare cytotoxic medication. Place a ‘Do Not Enter’ sign on the door (Rationale 4).
- Collect all the necessary equipment.
- Check cytotoxic medication according to the GOSH Medicine Administration Policy, the child’s treatment protocol, health record and prescription chart or Chemocare chart (Rationale 16).
- All cytotoxic medicine checks require two registered practitioners to undertake a 'high risk' check in accordance with the Medicine Administration Policy.
- Ensure doses of cytotoxic medication are appropriate for the child’s body surface area or weight according to protocol.
- Ideally, tablets should never be crushed or halved and capsules should never be opened. If it is not possible to administer a dose without doing so, contact the cytotoxic pharmacist for advice (GOSH 2006)(Rationale 20).
- Oral formulations of cytotoxic drugs should not be handled directly. Gloves should be worn at all times (Rationale 4).
- Doses of liquid preparations of oral cytotoxic drugs should be withdrawn from the container over a plastic tray. Once withdrawn, a cap should be placed on the syringe tip prior to administration (Rationale 23).
- Take the tray containing the cytotoxic medication and the child’s medication chart to the area where the chemotherapy is being administered.
- Ensure the child and family have received a full explanation of the treatment they are to receive and allow time to ask questions.
- Double check the cytotoxic medication according to the child’s prescription chart, against the child's identification bracelet, ensuring:
- Correct patient name in full.
- Correct date of birth.
- Correct patient ID number.
- Correct drug and dosage for surface area.
- Expiry date and time of drug.
- Administer cytotoxic medication as prescribed.
- Take the plastic tray containing all equipment to an area where it can be safely disposed of (Rationale 9).
- Dispose of all waste appropriately.
- Clean the plastic tray with soap and water then dry and return to storage.
- Remove all PPE and dispose of as cytotoxic waste.
- Wash hands with antibacterial soap and dry thoroughly.
- Administrator and second checker should sign the appropriate section of the medication chart.
If parents/carers are required to administer oral cytotoxic medication they should be aware of the necessary safety precautions and may wear gloves at home, specific for this use (Rationale 1).
Administration of an intravenous bolus injection of a cytotoxic drug via a central venous access device
Staff administering IV cytotoxic drugs should be assessed as competent to administer cytotoxic medication.
Follow steps 1-8 detailed above for safe administration of oral cytotoxic medication.
- Put a plastic apron on and wash and dry hands thoroughly (Rationale 21).
- Clean all surfaces of a plastic tray with a 2% chlorhexidine in 70% isopropyl alcohol wipe (eg Clinell® wipes or other Trust-approved product) for 30 seconds using friction and allow to dry naturally. Visibly check the device is dry. Wash hands for a second time, dry thoroughly and put on PPE (Rationale 21).
- Open needle(s) and connect to syringe(s). Draw up sodium chloride 0.9%, heparin flushes and antiemetics if required. Remove needles and place syringes in the plastic tray.
Follow steps 9-12 detailed above for the safe administration of oral cytotoxic medication.
- Locate the venous device to be used and clean the catheter hub with a a 2% chlorhexidine in 70% isopropyl alcohol wipe (eg Clinell® wipes or other Trust-approved product) for 30 seconds using friction and allow to dry naturally (Rationale 21). Visibly check the device is dry for 30 seconds (Rationale 21).
- Attach a syringe to the venous device, open clamp and withdraw 1-2ml blood (Pan London guidelines 2011 section 7.7-7.9) then flush the catheter with 2-5ml 0.9% sodium chloride. Observe for signs of pain, redness, swelling or leakage. Administer anti-emetics if required and flush from catheter (Rationale 22).
- Unscrew the cap of the syringe containing the cytotoxic medication (Rationale 23).
- Attach the luer lock to the venous access device and administer the medication over the necessary period of time. When medication has been administered, remove the syringe from the catheter and place in the tray.
- Flush the catheter according to the flush volumes for central venous access devices (CVADs) guideline (Rationale 24).
Follow steps 13-18 of the guidelines for the safe administration of oral cytotoxic medication.
Administration of intravenous cytotoxic medication as an infusion via a central venous access device
Staff administering intravenous cytotoxic drugs should be assessed as competent to administer cytotoxic medication.
Follow steps 1-8 as per guidelines for safe administration of oral cytotoxic medication.
- Ensure an administration pump is available and in full working order.
- Put on plastic apron and wash and dry hands thoroughly (Rationale 21).
- Clean all surfaces of plastic tray with a 2% chlorhexidine in 70% isopropyl alcohol wipe (eg Clinell® wipes or other Trust-approved product), allow to dry naturally (Rationale 21).
- Wash hands for a second time, dry thoroughly and put on PPE.
- Open needle(s) and connect to syringe(s). Draw up saline and heparin flushes and anti-emetics if required. Remove needles and place syringes in plastic tray.
- Open bag of fluid and buretted intravenous administration giving set. Prime the intravenous tubing with appropriate fluid ensuring a minimal amount of fluid remains within the burette.
- Cut open the plastic bags containing infusion bag of chemotherapy and empty into plastic tray.
- Remove fluid bag used to prime intravenous set and discard. Attach bag of chemotherapy. Always attach bags of chemotherapy of giving set over a plastic tray (Rationale 25).
Follow steps 9-12 as per guidelines for the safe administration of oral cytotoxic medication.
- Locate the venous device to be used and clean the catheter hub with a a 2% chlorhexidine in 70% isopropyl alcohol wipe (eg Clinell® wipes or other Trust-approved product) for 30 seconds using friction and allow to dry naturally. Visibly check the device is dry for 30 seconds (Rationale 21).
- Attach a syringe to the venous device, open clamp and withdraw 1-2ml of blood (Pan London guidelines 2011 section 9.7-9.9) then flush the catheter with 2-5ml of 0.9% sodium chloride. Observe for signs of pain, redness, swelling or leakage. Administer anti-emetics if required and flush from catheter (Rationale 22).
- Unscrew cap on end of buretted set and attach to the end of device.
- Place buretted set into infusion device and turn on. Set a volume limit of 20mls with pressure limits between 30-50mmHg. Open clamps and set a rate of 100-200ml/hour. Start the infusion pump (Rationale 26).
- Once the lines are primed, reduce infusion rate according to the prescription and re-set volume limit.
- Double-check all limits and rates with second checker.
- Pump pressures should be set to 30-50mmHg or 15-25mmHg for vesicant drugs (Rationale 27).
- Assess and record infusion and pressure limits hourly.
Follow steps 13-18 of the guidelines for the safe administration of oral cytotoxic medication.
- When the infusion has finished ensure the buretted set is flushed adequately with 20mls to clear the infusion set of cytotoxic medication (Rationale 24).
- Disconnect the set and flush the catheter according to the flush volumes for central venous access devices (CVADs) guideline (Rationale 24).
- Dispose of all equipment as cytotoxic waste ( Rationale 9).
Administration of vesicant cytotoxic medication via a peripheral route
Staff administering intravenous cytotoxic vesicant drugs peripherally must be competent to administer cytotoxic medication and have received additional training by a named assessor to be deemed competent to do so. A record of competent nurses is kept on the Trust chemotherapy register and is maintained by the lead chemotherapy nurse.
Names of assessors can be sought from the ICI-LM Education team.
If the administration is via a peripheral cannula, certain criteria should be adhered to:
- The cannula should have been in situ for no more than 48 hours (Rationale 30).
- The cannula should be a small gauge (24, 22) to ensure adequate blood flow within the vessel (Rationale 31).
- The cannula should be sited in a suitable area not near joints or in the ante-cubital fossa (Rationale 35).
- The cannula site should be clearly visible throughout the administration of the medicines. All bandages should be removed (Rationale 30).
Ensure adequate blood flow from the device to be used. 1-4ml of blood should flow freely on aspiration of the device ( Rationale 32).
Flush the device with 5-10ml of 0.9% sodium chloride and observe for signs of pain, swelling or leakage (Rationale 33).
When administering the drug, blood return should be monitored throughout, every 2ml of drug administered. A flashback of blood is sufficient in this instance (Rationale 34).
Ensure the device is adequately flushed after drug administration (Rationale 24).
Document site of administration and drug given along with any problems in the child's medical notes (Rationale 27).
Administration of cytotoxic medication as an intramuscular injection
Staff administering intramuscular cytotoxic medication should have been assessed as competent to administer cytotoxic medication.
Follow steps 1-12 detailed above for safe administration of oral cytotoxic medication.
Follow clinical procedure guideline for intramuscular administration in the Manual of Children's Nursing Practices (MacQueen, Bruce and Gibson, 2012).
Follow steps 13-18 of the guidelines for the safe administration of oral cytotoxic medication.
Administration of cytotoxic medication as a subcutaneous injection
Staff administering subcutaneous cytotoxic medication should have been assessed as competent to administer cytotoxic medication.
Follow steps 1-12 detailed above for safe administration of oral cytotoxic medication.
Follow clinical procedure guideline for intramuscular administration in the Manual of Children's Nursing Practices (MacQueen, Bruce and Gibson 2012).
Follow steps 13-18 as detailed above for the safe administration of oral cytotoxic medication.
Management of adverse reactions and complications
Patients receiving cytotoxic medication should be observed regularly for signs of adverse reactions and complications (Rationale 36).
- Check sensitivity to medication prior to administration (Rationale 36).
- Have appropriate anti-histamines available if anaphylaxis is a possibility.
- Ensure emergency equipment is available, including oxygen and resuscitation equipment.
- Ensure you are familiar with the Resuscitation Council algorithm for children experiencing anaphylactic reactions.
- Inform the child and their family of the possibility of allergic reactions.
- Obtain baseline observations prior to administration of the cytotoxic medication (Rationale 37).
- Patients receiving L-Asparaginase should remain in a clinical area for one hour following administration (Rationale 36).
- Inform the child and family of the possibility of a skin rash (Rationale 38).
- Administer an anti-histamine if required.
- Apply lotion if required.
- Observe for changes or pain.
- Document in the child medicine chart and health care record.
The treatment of suspected or known extravasation must be in accordance with the GOSH Extravasation and infiltration guideline.
Rationale 1: To decrease the risk of patients and their families being exposed to cytotoxic medication.
Rationale 2: To decrease the risk of occupational exposure to cytotoxic/cytostatic medication.
Rationale 3: Cytotoxic/cytostatic drugs can be toxic to normal cells causing unwanted side effects.
Rationale 4: These policies detail the expected standards of practice required to ensure appropriate patient care and the safety of staff.
Rationale 5: Cytotoxic/cytostatic medication can remain in the patient's excreta for up to seven days following administration.
Rationale 6: Guidance from the Health and Safety Executive (HSE) for new and expectant mothers emphasises that "a safe level of exposure cannot be determined for these drugs, so you should avoid exposure or reduce it to as low a level as is reasonable practicable" (HSE, 2004).
Rationale 7: To ensure all staff injuries are recorded and practices re-evaluated and that the individual adheres to the hospital policy.
Rationale 8: To comply with control of substances hazardous to health regulations (2011).
Rationale 9: To comply with the GOSH Waste Management Policy (2013).
Rationale 10: To comply with the policy for prescribing, dispensing, supply and administration of intrathecal and intraresevoir cytotoxic injections at Great Ormond Street Hospital (2014) and the updated national guidance on the safe administration of intrathecal chemotherapy (2008).
Rationale 11: The administration of cytotoxic drugs to patients without ensuring all pre-chemotherapy tests have been completed can lead to dangerous toxicity.
Rationale 12: Many cytotoxic agents are vesicants and will cause extreme tissue damage if leakage occurs from the vein eg vincristine, daunorubicin.
Rationale 13: The risk of accidents is increased when complex cytotoxic regimens are given outside normal working hours, particularly errors of incorrect drug and patient identification, and using the incorrect route of administration of cytotoxic drugs (Pan London guidelines 2011).
Rationale 14: A consultant oncologist or haematologist must determine that it would be absolutely inappropriate to delay commencing chemotherapy. The decision must be recorded in the medical notes by the responsible consultant (Pan London guidelines for the safe prescribing, handling and administration of systemic anti cancer treatment drugs 2011).
Rationale 15: To maintain a record for audit purposes.
Rationale 16: To ensure the correct treatment is given.
Rationale 17: To ensure the child is physically well enough to receive treatment.
Rationale 18: To adequately prepare the child and family.
Rationale 19: To complete pharmacy records.
Rationale 20: There is a risk of inhalation from the powder released during the crushing and halving of tablets and in opening of capsules.
Rationale 21: To adhere to aseptic non touch technique.
Rationale 22: To ensure the patency of the central venous access device being used.
Rationale 23: All cytotoxic medication prepared for intravenous or oral use should be capped until administration to prevent possible spillage.
Rationale 24: To ensure all chemotherapy has been flushed.
Rationale 25: To contain any possible spillage and reduce contamination.
Rationale 26: This will prime the infusion set with the cytotoxic medication contained within the burette and ensure the total infusion time is not delayed.
Rationale 27: To detect possible extravasation.
Rationale 28: To ensure all of the drug is received.
Rationale 29: To minimise the risk of catheter occlusion.
Rationale 30: To ensure the cannula is safe to use.
Rationale 31: To reduce the risk of phlebitis which can lead to extravasation.
Rationale 32: To ensure adequate blood flow.
Rationale 33: To reduce damage or potential injury should extravasation occur.
Rationale 34: To determine that the device is still within the vessel.
Rationale 35: To minimise the risk of extravasation injury.
Rationale 36: Some cytotoxic medication can cause allergic reactions during or immediately following administration eg asparaginase, melphalan, carboplatin.
Rationale 37: To ensure baseline observations are documented in the case of anaphylactic reaction.
Rationale 38: Some cytotoxic drugs can cause skin rashes during or immediately following administration eg cytarabine.
Department of Health (2008) Updated National Guidance on the Safe Administration of Intrathecal Chemotherapy. Department of Health, Department of Health.
European Oncology Nursing Society (2007) Extravasation Guidelines 2007. European Oncology Nursing Society Guidelines (e-pub)
Health and Safety Executive (HSE) (2004) New and Expectant Mothers at Work: a guide for employers. Surrey, Health and Safety Executive.
Health and Safety Executive (HSE) (2014) Safe handling of cytotoxic drugs in the workplace. Health and Safety Executive (e-pub) [last viewed on 18.03.2015]
HMSO (2005) The Hazardous Waste (England and Wales) Regulations 2005 [last viewed on 16.06.2015]
MacQueen, Bruce, Gibson (Eds) (2012) The Great Ormond Street Hospital Manual of Children's Nursing Practices. Wiley-Blackwell, West Sussex
Pan London (2011) Guidelines for the Safe Prescribing, Handling and Administration of Systemic Anti Cancer Treatment Drugs [accessed on 03.07.2015]