Rosemary Monsell BSN RN ONC - MWH 4 North
Chemotherapy safety is a great concern not only for patients but for the
nurses that administer these lifesaving medications. Starting a Chemotherapy
Safety Initiative Project was the focus of my ACE III project. This is
an ongoing task force collaborating with Dr. Mauer's office, Infusion
center, Pharmacy, Laboratory, and our EVS departments.
Our goals were:
- Increase the safety of administration of chemotherapy.
- Increase CNA education re: handling body fluids of chemotherapy patients.
- Identify patients who are currently receiving or have received chemotherapy
in the past 48 hours by using a blue cart on the patient's door.
We first determined that all 4 North nurses would complete the ONS Chemotherapy
Biotherapy Certificate Course to ensure that only Chemotherapy Certificate
nurses administer chemotherapy. We also determined that we should follow
the ONS recommendations of using proper personal protective equipment
or PPE to include chemotherapy approved gloves and gowns. Our task force
determined that we were not using proper PPE by not wearing chemotherapy
approved gowns while administrating chemotherapy.
All 4 North nurses are now currently working towards completing the ONS
Chemotherapy Certificate Course. Hopefully all will be completed by the
end of 2016. We now include chemotherapy approved gowns in our PPE for
chemotherapy administration and all 4 North nurses have had education
on proper use of the PPE. We now have blue carts that are placed on a
patient's door to identify them as chemotherapy patients. Ongoing
education continues for staff on proper handling of body fluids.
We are currently working with Pharmacy, Lab, and EVS on how to manage
chemotherapy spills. We are also working with Dr. Maurer's office,
Pharmacy and our IT department on implementing chemotherapy orders via
COPE. We also work with our Education department to provide ongoing education.