# POL-CW-04 — Hazardous drugs (chemotherapy) safety

**Riverside Children's Cancer Centre — Cedar Ward**
**Owner:** Pharmacy (Dr S. Khoury) with Nursing
**Version:** 4.0
**Date:** 19 November 2025
**Review due:** 19 November 2027
**Applies to:** staff preparing or giving parenteral chemotherapy to patients aged 0–21 years on Cedar Ward
**Status:** current — teaching copy, not a real hospital policy

## 1. Purpose

To protect staff, families, and other patients when hazardous drugs are mixed, given, or spilled.

## 2. Who this covers

Paediatric and adolescent/young-adult patients **aged 0–21 years** receiving parenteral chemotherapy on Cedar Ward. Oral maintenance at home is out of scope.

## 3. Closed system and PPE

A closed-system transfer device is mandatory for all parenteral hazardous drugs.

PPE for administration: chemo gown, double chemotherapy gloves, eye protection if splash is possible. A surgical mask is enough; an N95 is not required for ordinary administration.

Pregnant staff may not mix hazardous drugs. They **may administer** a connected infusion if a second nurse spikes the bag.

## 4. Counts before a cycle

Do not start a myelosuppressive cycle if ANC is 1000/µL or lower, unless the protocol says otherwise (for example induction for AML).

## 5. Fever during a chemotherapy admission

If a child spikes a fever while an infusion is running, **stop the infusion**, call the registrar, and ask the family to **contact the day unit the next morning** if the child is otherwise well. Night fever after a day-unit infusion is handled by the day unit, not ER.

## 6. Extravasation

Stop the infusion. Aspirate through the existing cannula. Do not flush.

- Vinca alkaloids (vincristine, vinblastine): warm compress, hyaluronidase if available.
- Anthracyclines (doxorubicin, daunorubicin): **warm compress** for 20 minutes, four times a day, for 24 hours. Elevate the limb. Call pharmacy.

## 7. Spill kit

The chemotherapy spill kit is kept in **Room 12 clean utility**, on the top shelf, labelled yellow. Check the seal every Monday.

Do not store the spill kit in the dirty utility. That room is for waste only.

No live plants in rooms where chemotherapy is given.

## 8. PPE overlap with isolation

Gowns used for protective isolation (POL-CW-03) are not chemotherapy gowns. Do not mix the two stocks. Isolation gowns and the chemo spill kit must not share a cupboard.

## 9. Related documents

- POL-CW-01 Febrile neutropenia
- POL-CW-02 Central venous access devices
- POL-CW-03 Visitor and protective isolation