is it safe to mix your own chemo in an outpatient oncology setting?

BeachsideRN, ASN · Mar 9, 2014

Interested in responses. Following.

OCNRN63, RN · Mar 9, 2014

You can, and should, get your chemo provider card (it is not a certification) through ONS. (http://www.ons.org) I think your situation is a case of "You don't know what you don't know." If you take the chemo provider course, you'll find out there's a lot to know about chemotherapy and administering meds.

Where I worked, we double-checked everything before administration. Every now and then, mistakes were caught. You can't be too careful.

When I first started working in OP oncology, the nurses took turns mixing meds. After I was there about a year, all mixing was taken over by pharmacy.

gvrn13 · Mar 9, 2014

Hi, thanks for responding.. I am a member of the ONS, and I think it would be good for me to get the chemo provider card, I think that would make me feel more comfortable. I don't think my job will be going over to a pharmacy providing the mixing. I like that your job made you double check all medications, this seems like the safest way to me.. Maybe my job doesn't do it because it's too time consuming? Each nurse has on average 5-7 patients per day, and there are usually 2 nurses. It can get hectic doing your own schedule, if you had to check somebody else's calculations too it might be too much.. but what is too much when it comes to being safe? Did your practice use pumps, or did you just do drip rates?

SoldierNurse22, BSN, RN · Mar 9, 2014

Are you saying you're not certified to give chemo? As in, you haven't taken the Chemo & Biotherapy provider course?

If so, I'm amazed and a bit disturbed that you're allowed to handle chemotherapy at all.

gvrn13 · Mar 9, 2014

No, I am not certified, and I have not taken the provider course. My job did not require the provider course (I really have only found out about it recently), but it is encouraged that I become certified when I am eligible. Have you worked in outpatient oncology before? If you have, I would like to hear how your practice maybe differs from mine. While writing you are amazed and disturbed is fine, if you have anything more constructive to add I would appreciate the feedback. Like I said, I am a new nurse, and was really happy that I found a job fairly easily, and I took what my supervisors and fellow infusion nurses said for face value.. Now a few months in though, I am wondering if what I am doing is ok. I mean, does the law require you to take the provider course, and be certified?? Maybe how this practice does things is not ideal, but is it wrong?

SoldierNurse22, BSN, RN · Mar 9, 2014

I worked both outpatient and inpatient oncology.

I'm stunned because of the level of risk associated with chemotherapy, especially the mixing piece. It was risky to the point where they created an oncology pharmacy full of folks whose sole purpose in life was to mix our meds for us to reduce our risk of exposure.

To allow a nurse who has not been trained in the basics of handling chemotherapy and the patients who are exposed to mix, administer and monitor oncology patients it is simply unthinkable by the standards I was taught. By neglecting to ensure that you have adequate training, your facility is not only putting you at risk, but your patients as well.

gvrn13 · Mar 9, 2014

Thanks for you input… I was really wondering what other outpatient facilities do. I'm not sure if you still do outpatient, but you do make a good point about by my employer not requiring the chemo provider course, they are putting both me and my patients at risk. I wouldn't say that my training was inadequate though, maybe just not as detailed as it possibly could've been?? I shadowed an OCN for WEEKS, and when I did start mixing and hanging, she was shadowing me. Regardless, I will work on doing the chemo provider course. Being so new, in an office setting, it's kind of easy to be persuaded, and talked into what the standard is for that particular place. I feel like in a hospital, the training and standards are just such higher.. I do have an interview for the emergency department in a local hospital, and I am just hoping with everything I have that I get this job!!

OCNRN63, RN · Mar 10, 2014

Hi, thanks for responding.. I am a member of the ONS, and I think it would be good for me to get the chemo provider card, I think that would make me feel more comfortable. I don't think my job will be going over to a pharmacy providing the mixing. I like that your job made you double check all medications, this seems like the safest way to me.. Maybe my job doesn't do it because it's too time consuming? Each nurse has on average 5-7 patients per day, and there are usually 2 nurses. It can get hectic doing your own schedule, if you had to check somebody else's calculations too it might be too much.. but what is too much when it comes to being safe? Did your practice use pumps, or did you just do drip rates?

We ran our chemo on pumps.

Are you double-checking labs before you give your chemo? (e.g. checking ANC, H&H, BUN&Cr, etc?)

I agree with Soldier; it's very disconcerting that you are mixing and giving chemo with no double check and without proper education. The ONS Chemotherapy/Biotherapy Course is now all online, so you could do it during downtime and at home. You will get a good chunk of CEUs for it.

You really need to do this, not only for the safety of your patients but for your own safety as well.

OCNRN63, RN · Mar 10, 2014

No, I am not certified, and I have not taken the provider course. My job did not require the provider course (I really have only found out about it recently), but it is encouraged that I become certified when I am eligible. Have you worked in outpatient oncology before? If you have, I would like to hear how your practice maybe differs from mine. While writing you are amazed and disturbed is fine, if you have anything more constructive to add I would appreciate the feedback. Like I said, I am a new nurse, and was really happy that I found a job fairly easily, and I took what my supervisors and fellow infusion nurses said for face value.. Now a few months in though, I am wondering if what I am doing is ok. I mean, does the law require you to take the provider course, and be certified?? Maybe how this practice does things is not ideal, but is it wrong?

Neither are required but consider a scenario where a patient is harmed during their infusion, and they sue. The patient's attorney is going to ask you what kind of education you have to make you qualified to administer chemo. They may ask you if you've taken the ONS course. If you can't provide adequate education and training, you're really going to be in hot water.

I would strongly suggest that you join ONS. It's ~$100 to join, but you get discounts on CEU, courses, and reading materials. Get the manual for Chemotherapy/Biotherapy Administration; it will help you when you take the course (which you are going to do), and it's a good reference manual for day to day practice. I would also suggest getting the ONS Core Curriculum for Oncology Nursing. It reviews the major oncology diseases you'll encounter, the different oncologic emergencies and professional practice.

Do you have an experienced nurse who can act as your mentor?

SoldierNurse22, BSN, RN · Mar 10, 2014

Thanks for you input… I was really wondering what other outpatient facilities do. I'm not sure if you still do outpatient, but you do make a good point about by my employer not requiring the chemo provider course, they are putting both me and my patients at risk. I wouldn't say that my training was inadequate though, maybe just not as detailed as it possibly could've been?? I shadowed an OCN for WEEKS, and when I did start mixing and hanging, she was shadowing me. Regardless, I will work on doing the chemo provider course. Being so new, in an office setting, it's kind of easy to be persuaded, and talked into what the standard is for that particular place. I feel like in a hospital, the training and standards are just such higher.. I do have an interview for the emergency department in a local hospital, and I am just hoping with everything I have that I get this job!!

I was on the oncology ward for 6 months before I took the provider course. During that time, I was not allowed to handle chemotherapy, much less mix and give it. I shadowed an RN on the ward for 1 month prior to the chemo course, took the 2-day chemo course (back then, it was taught in person), did a week of strictly clinic work with a preceptor, and then completed 3 observed chemotherapy administrations before I was allowed to give it alone back on the ward.

Suffice to say our definitions of "adequate" vary greatly.

While I have no doubt that you learned a lot while you were shadowing, there is a reason that in nursing school, you're taught theory before you're put into practice. There is a way things need to be done--a standard--and that's something everyone should know. A book (like the one we received at the chemo course) not only serves as a reference should you have questions once you're in practice, but as the foundation across the board for all nurses in a specialty. It sets the minimum expected standards across the board, not based on one person's arbitrary practice, but on researched, proven methods that will protect you and your patient. I'm not trying to discredit your preceptor, but understand that you need to take responsibility for your practice, and without a pulse on the basic standards of practice for your specialty, you're gambling your license and your patients on the word of another nurse. That is never, never, never a good idea. Trust no one but yourself and solid research.

I understand the pressure that's probably on you to perform to a certain standard, but you have a license now and the awareness of your own safety and that of your patients needs to come over what an employer/preceptor wants you to do, no matter if it's the crustiest old bat in the place telling you you'll be fine or your manager. There are worse things than being unemployed.

gvrn13 · Mar 10, 2014

Hi, thanks for responding. I absolutely run a CBC on every one of my patients, and depending on how the counts are, I will run it by the doctor.. if the Hgb is below 10, if they aren't already receiving Epogen, if the WBC are low ( or very high), and the ANC is below 1.4, if the Platelets are below 100. All patients have a CMP done monthly (I've been told this is what most insurance allow). If somebody is on something like Carbo, a CMP is done at every treatment, so we will have a Crea to help calculate the dose at the next treatment. Of course, if a person doesn't feel well, or has something going on ex. unrelieved nausea, diarrhea, mouth sores, fatigue, or abnormal vital signs this I would bring to the doctor on duties attention as well. I feel like I should have been made to do the chemo provider course, why I wasn't I'm not sure, because they really encourage all the nurses to become certified. And I will be doing the course, and I agree that it is in my best interest as well as my patients.