1.1 Chemotherapy orders, and any modifications to such orders, shall be prescribed only by the persons and only in the manner permitted for the issuance of treatment orders by the Rules and Regulations of the Medical Staff ("Authorized Prescribers")

1.2 Members of the House Staff may write chemotherapy orders, and any modifications thereto, subject to the following restrictions:

1. An order for a patient’s first cycle of chemotherapy must be reviewed and countersigned by the member of the Staff who is responsible for the patient’s chemotherapy before administration of such first cycle is initiated.
2. Orders for chemotherapy, other than a patient’s first cycle of chemotherapy shall be countersigned by a member of the Staff in accordance with the requirements for counter signature of treatment orders.

1.3 Verbal orders relating to a patient’s chemotherapy are acceptable only when all of the following conditions are met:

1. The patient requires immediate treatment and the authorized prescriber is not immediately available.
2. The verbal order is issued by the Authorized Prescriber.

1.3.2 The verbal order is a modification of an existing chemotherapy order signed in accordance with Sections 1.2.1 or 1.2.2.

3. The modification, if outside of specified guidelines, must be signed by the authorized prescriber as defined by Rules and Regulations Medical Staff.
4. The verbal order is given directly to a Registered Nurse, certified Physician Assistant or licensed Pharmacist. The order must be repeated to the authorized prescriber and then immediately written in the patient’s chart. Verbal chemotherapy orders shall not be relayed from person to person before they are written into the patient’s chart.

3. Orders for investigational chemotherapeutic agents may be prescribed only by Authorized Prescribers who are listed as principal investigators or co-investigators on a research study approved by the Human Subjects Committee. Fellows, who are members of the House Staff and under the direct supervision of the Authorized Prescriber listed as the principal investigator or co-investigator on the Approved Research Study may also write such orders.

2.1 Chemotherapy order forms shall be utilized for all antineoplastic agents with the following exceptions:

    Pleurodesis therapy                 Topical therapy

    Methotrexate for GVHD         Bladder Irrigations

    Hydroxyurea                                 Medicated Implants

                                  Oral Chemotherapeutic Agents

2.2 Other Chemotherapy Order Forms may be used, subject to the approval of the Medical Records Committee, the Medical Executive Committee and the Authority, and may be utilized for :

          - commonly used chemotherapy regimens.

- investigational chemotherapy protocols.

2.3 A complete chemotherapy order will consist of:

2.3.1 Patient name and hospital ID number

2.3.2 Diagnosis

2.3.3 Patient height and weight when needed for dosing of agents

2.3.4 Designation of KUMC protocol # or investigational study name #

2.3.5 Start date

2.3.6 Laboratory criteria necessary for treatment decision-making (e.g. AGC>1000)

2.3.7 Drug name (generic name preferred). All unclear names are to be clarified prior to order entry and/or administration to the patient.

2.3.8 Proper sequence of administration

2.3.9 Dose per m² or dose per kg written or verified by the physician..

2.3.10 Calculated dose clearly written by the physician or pharmacist.

2.311 Rate ( e.g. Bolus, 24 hour continuous infusion, 2 hour infusion).

2.3.12 Interval ( q 12hr, q 24hr, q week)

2.3.13 Route (e.g. IV, PO, IM, SQ, intrathecal, intraperitoneal, limb perfusion, hepatic embolism).

2.3.14 Duration or total number of doses (e.g. x 4 doses, x 1 dose)

2.3.15 Ancillary IV=s or medications necessary for treatment (e.g., mannitol 12.5g IVP, hydration fluids).

2.3.16 Antiemetics or an indication for pharmacist to prescribe per guidelines.

2.3.17 Physician signature and date.

2.3.18 Consent form, signed by the patient prior to the first dose of investigational chemotherapeutic protocols.

3.0 Chemotherapy Order Processing and Timeliness

The University of Kansas Hospital recognizes the value of interdisciplinary review of the chemotherapy and the importance of patient satisfaction in the timing of therapy. As such, all Authorized Prescribers who issue orders for chemotherapy shall adhere to the following:

3.1 To facilitate safety and timeliness, it is preferable that chemotherapy orders for scheduled admissions to be administered within the facility be submitted to the pharmacy department at least 12 hours before the patient is scheduled to receive therapy. Exceptions to the 12 hour requirement, to enhance patient satisfaction while maintaining safety, will be made as staffing, space and workload allow.

3.2 The Authorized Prescriber who issued the chemotherapy order, or a fellow who is a member of the House Staff under the supervision of the Authorized Prescriber, shall be available to the nurse and pharmacist for clarification and adjustments of the chemotherapy order as necessary.

4. Protocol Verification
1. The Department of Pharmacy will maintain a listing officially designated as the "University of Kansas Hospital Chemotherapy Protocol Handbook"("Protocol Handbook") which shall contain a) all protocols and associated guidelines currently approved for use in the Hospital; and b) an updated list of Hospital- approved exceptions to said protocols.
2. All chemotherapy orders shall adhere to protocol or exception that appears in the Protocol Handbook, or that can be independently confirmed via a formal reference (i.e., textbook, abstract, protocol, handbook). In the case of the latter, the chemotherapy order shall cite the reference upon which the order is based, and a copy of the reference shall be attached to the Chemotherapy Order Form.
3. A chemotherapy order which does not comply with Section 4.2 will not be dispensed, and the pharmacist who received the order shall notify the Authorized Prescriber of such immediately.

4.3.1 If the Authorized Prescriber who issued the noncompliant order writes the missing citation on, and attaches a copy of the reference to, the Chemotherapy Order Form, the order shall be deemed compliant, and the pharmacist shall dispense accordingly.

2. If the Authorized Prescriber chooses to modify the regimen so that it adheres to a documented protocol which meets the requirements of Section 4.2, a new order will be required, and the pharmacist will dispense accordingly.
3. In the event that the Authorized Prescriber who issued the order is unable to provide the documentation required by Section 4.2 and desires that the order remain as written, the pharmacist, or his/her designee, shall refer the order to the Chair, of the Pharmacy and Therapeutics’ Chemotherapy Subcommittee or to the Chair’s designee.

4.4 The Chair of the Pharmacy and Therapeutics’ Chemotherapy Subcommittee, or his/her designee, upon receipt of a referral from the pharmacist pursuant to Section 4.3.3 shall review the order and, as necessary in his/her discretion, discuss the order and any other relevant matters with the pharmacist who referred the order and the Authorized Prescriber who issued the order.

1. If the Chair, or his/her designee, determines that the order is correct as written and meets the requirements of Section 4.2, he/she shall indicate that the dose may be dispensed as written.

2. If the Chair, or his/her designee, cannot determine that the order is correct as written and meets the requirements of Section 4.2, he/she may recommend either that the order be rewritten so that it comply with 4..2 or that the Authorized Prescriber seek a Compassionate IND.
3. If the Chair, or his/her designee, determines that the order contains a protocol which is investigational, he/she shall refer the order to the Human Subjects Committee of the Hospital for approval.

4. The Chair, or his/her designee, shall communicate any recommendation to both the Authorized Prescriber who issued the order and the pharmacist for subsequent action.
5. The pharmacist shall document the initiation and outcome of the dose verification process outlined in this Section 4.4 on the Chemotherapy Order Form and forward the Chemotherapy Order Form to the Pharmacy and Therapeutics Committee for review.

4.5 Any nurse who questions whether a chemotherapy order complies with Section 4.2 shall follow dose verification guidelines as outlined in the Department of Nursing Governance Standards, Tech-03, Administering Intravenous Chemotherapeutic Agents.

1. MR Cohen, RW Anderson, RM Attilio, L Green, RJ Muller. Preventing medication errors in cancer chemotherapy. Am J Health-System Pharm. 1996; 53:737-46

2. Medical Staff By-Laws Rules and Regulations. H. Lee Moffitt Cancer Center. May 1996

3. ASHP guidelines on preventing medication errors in hospitals. Am J Hosp Pharm 1993; 50:305-314

4. MR Cohen. Stop the guessing games over proper dosing for cancer drugs; value of computer generated MARS. Hospital Pharmacy 1995; 30: 642-6244

5. RM Attilio. Caring enough to understand: The road to oncology medication error prevention. Hospital Pharmacy 1996; 31:17-26

6. Proceedings: Understanding and preventing drug misadventures. Am J Health System Pharm. 1995; 52:369-416

7. TW Ross. Applying performance improvement to optimize oncology therapy. Hospital Pharmacist Report 1997; 11:44-53

8. DS Fischer , S Alfano, MT Knobf, C Donovan, N Beaulieu. Improving the cancer chemotherapy process. Journal of Clinical Oncology. 1996; 14:3148-3155.

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