6: BRIEF RESUME OF THE INTENDED WORK

6.1.INTRODUCTION:

“Health should mean a lot

more than

escape from death or, for

that matter,

escape from desease”.

(K.Park)1

Cancer is the group of more than 200 diseases characterized

by uncontrolled and unregulated growth of cells. It is the major

health problem that occurs in people of all ethnicities.

Although, cancer is often considered a disease of aging, with the

majority of cases diagnosed (76%) in those over the age of 55

years, it occurs in people of all ages. Globally cancers accounts

for 5.1% of total disease burden and 12.5% of all deaths.1

Many management options for cancer exist including:

chemotherapy, radiation therapy, surgery, immunotherapy,

monoclonal antibody therapy and other methods which are used

depending upon the location and grade of the tumour and the stage

of the disease, as well as the general state of a person's

health.2

Chemotherapy is a kind of treatment that uses drugs to

attack cancer cells. It is called a "systemic treatment" since

the drug, entering through the blood stream, travels throughout

the body and kills cancer cells at their sites. The drugs may

rarely be intended to have a local effect, but in most cases, the

intention is to destroy cancer cells wherever they may exist in

the body. Since chemotherapy also affects normal actively

dividing cells such as those in the bone marrow, the

gastrointestinal tract, the reproductive system and in the hair

follicles, most patients experience some degree of side effects

like nausea, vomiting, hair loss, mouth sores, ulcers.3

Chemotherapy is now a mainstay of cancer therapy used in the

treatment of most of solid tumours and hematologic malignancies

like leukaemia’s, lymphomas, myeloma and myelodysplastic

syndromes.1

One of the primary responsibilities of the nurse in the

delivery of chemotherapy is to ensure that the correct dose of

the appropriate drug is given to the appropriate individual.

Despite the fact that safeguards are in place, serious medication

errors do occur. Such tragic events are regrettable but not so

remarkable when one considers the number of chemotherapy doses

given and the number of patients treated. The overall medication

error rate is estimated to be 2-10%. However, one recent survey

revealed that 63% of the respondents reported that errors had

occurred at their workplace. In addition only 3% of the errors

were reported to drug manufacturers or national databases though

most were reported internally. 4

Safe handling of chemotherapeutic agents during

administration and disposal is critical. Most antineoplastic

agents are toxic compounds that are carcinogenic, mutagenic, or

teratogenic. Direct contact may cause irritation of the skin,

eyes, and mucous membranes. Perioperative personnel should know

how to handle hazardous materials safely to protect the patient,

other staff members, and themselves. These safety precautions

include appropriately identifying the patient; correctly

preparing, verifying, and documenting the chemotherapeutic agents

being administered; consistently wearing personal protective

equipment; transporting the chemotherapeutic agent in a puncture-

resistant container labelled “chemotherapy”; properly disposing

of the chemotherapeutic agent and supplies; and handling a spill

if one occurs.5

Educational programmes about cancer and safe handling of

cancer chemotherapeutic drugs provide the nurses to safeguard

themselves as well as patients. Dissemination and current

information permits the nurses in general practice and other

specialities to learn about recent advances in cancer research

and ongoing clinical trials. It also includes providing education

or information about staging, current treatment regimen, clinical

indication for use, guidelines of administration, and

manifestation of toxicity, appropriate intervention. In

addition , the health care professional much be familiar with the

medication, mode of action, side effects an appropriate

administration and disposal procedure.2

Cancer, is the multidisease phenomenon and the word

cancer came from the ‘Father of Medicine’, Hippocrates, a

Greek physican. Hippocrates used the Greek words, Carcinos

and carcinoma to describe tumors, thus killing cancer

‘Karkinos’. In Greek the words refer to ‘carb’2. It is also

found in the animal kingdom is most of the multi cellular

animals like mammals, fish, reptiles and amphibians.3

According to American Cancer Society (ACS), Cancer is a

group of disease characterized by uncontrolled growth and

spread of abnormal cells. If the spread is not controlled,

it can result in death.4

Cancer theraphy has progressed rapidly in the last half

of the 20th century. Many cancers once considred incurable

are now controlled with the discovery of different methods

like surgery, radiation, and chemotherpy.5 Consequently the

attitude towards cancer has become a more positive one bright

with hopes of recovery.2

The era of cancer therapy began in the 1940 with the

first use of nitrogen mustards and folic acid antagonist

drugs6. At the turn of century Paul Ehrlich, who coined the

term chemotherapy and was named the “Father of Chemotherapy”.

The modern era of chemotherapy was initiated by the discovery

of the effective use of estrogen in prostate and breast

cancer.7

Chemotherapy is the use of chemical agents to kill

cells. In conversational usage, the term chemotherapy

refers to the chemical treatment of cancer. Most people

associate chemotherapy with a myriad of horrible side

effects, such as hair loss and nausea. While these side

effects do often accompany chemo regimens, millions of

cancer patients have been able to enjoy long, vibrant

lives because of this treatment option. Furthermore,

chemotherapy side-effect management has progressed

significantly over the past few decades. Many of

chemo’s distressing side effects can be prevented

completely, or controlled using today’s advanced

treatment strategies1.

More than 50% of people diagnosed with cancer are

treated with chemotherapy. For some patients, chemo

serves as their only treatment, whereas other patients

are prescribed chemotherapeutic drugs alongside other

treatment options. In the 1940s, the United States

Department of Defense recruited two pharmacologists,

Louis S. Goodman and Alfred Gilman, to research the

therapeutic properties of chemical warfare agents.

Autopsy findings involving people exposed to nitrogen

mustard (mustard gas) unveiled conditions in the body

conducive to tumor suppression1.

After World War II, the scientific community

embarked on a number of cancer treatment research

projects. These projects included the groundbreaking

use of folate analogues to treat Indian children with

leukemia in 1948. Folate anologues antagonize folic

acid in cells. Folic acid is a vital component of

cellular metabolism. When cellular metabolism is

impaired, cellular division is disrupted, or the cell

dies. Using folate analogues was the first

demonstration of remission in all patients that were

given the chemical agent2.

In the 1950’s, the U.S. government began

incentivizing pharmaceutical companies to develop

anticancer drugs. Since this initial “push” to support

cancer research and drug development, cancer has been

receiving an enormous amount of political and social

attention around the world. This much-needed attention

has led to many breakthrough tests and treatment

options2. 

Chemotherapeutic agents are widely used in cancer

therapy because they can inhibit growth by disrupting

cell division and killing actively growing cells. With

increasing understanding of cell biology over the last

four decades, administration of antineoplastic agents

has become one of the most important modalities of

treating cancer2.

Chemotherapeutic drugs are grouped into alkylating

agents, nitrosoureas, antimetabolites, topiosomerase

inhibitors, antitumour antibodies, mitotic spindle

poisons, hormonal agents and miscellaneous drugs that

are not readily classifiable. Chemotherapeutic drugs

inhibit the process of mitosis, or cell division. Since

malignant (cancer) cells divide without control or

order, these drugs effectively target cancerous

growths. Some chemo drugs cause cancer cells to die

altogether by stimulating a process known as apoptosis

(programmed cell-death)3.

Although chemotherapeutic drugs are designed to

target fast-dividing cancer cells, they inadvertently

damage healthy cells. The faster a healthy cell

divides, the more likely it is to be affected by chemo.

This is why your hair may fall out during a chemo

regimen. The cells that compose the hair follicles

divide quickly3.

A study was conducted to indicate the increase in

the potential risk due to occupational exposure to

chemotherapeutic drugs. Nurses and pharmacists are the

main groups exposed to these drugs in the ambulatory

and hospital setting. The pharmacists are exposed to

these drugs while preparing them and the nurses while

administering them4.

6.1: NEED FOR STUDY Cancer is an abnormal cell growth and chemotherapy is a drug

regimen designed to stop that growth. Chemotherapy can also harm

healthy cells, according to the National Institutes of Health

(NIH), and cause side effects in cancer patients. Healthy cells

often recover and side effects gradually disappear in many cases.

Chemotherapy is administered intravenously, orally or

intrathecally. Without taking proper precautions, nurses and

other health industry workers can be exposed to the drugs.6

Cancer is the second most killing disease in the world

which affect man. Stewart (2003) stated that the global burden

of cancer continues to increase, Nearly 5.3 million and 4.7

million women developed malignant tumor and 6.2 million died from

the disease the number of new case is expected to grow by 50%

over the next 20 years to reach, 15 million by2020. 8

According to Global Cancer factsheet, an estimated 12.7

million new cancer cases occurred and 7.6 million deaths (around

13% of all deaths) in 2008. Lung, female breast, colorectal and

stomach cancers accounted for 40% of all cases diagnosed

worldwide. In men, lung cancer was the most common cancer (16.5%

of all new cases in men). Breast cancer was by far the most

common cancer diagnosed in women (23% of all new cases in

women).7

According to Department of Biostatistics and Epidemiology:

Kidwai Institute of Oncology, among males cancer of the stomach

is the  most predominant site of cancer constituting 9% of the

total cancers among males followed by cancers of the lung (7.0%),

oesophagus (6.6%), prostate (5.3%) and Non Hodgkin’s Lymphoma

(4.6%).  Among females, cancer of the breast is the predominant

site of cancer and has accounted for 24.6% of the total cancers

in females followed by cancer of the cervix (15.9%), ovary

(4.9%), oesophagus (4.7%) and mouth cancers (4.6%). Altogether,

the first ten leading sites of cancers among males and females

accounted for 53.1% of the total cancers in males and about 70.9%

of the total cancers in females.8

A number of studies documented adverse health effects that

are connected with occupational exposure to antineoplastic

chemotherapeutic agents. The most frequent acute toxicities noted

include nausea, vomiting, headaches, dizziness, hair loss, and

liver damage. These acute symptoms were positively correlated

with the number of doses handled and the use of protective

equipment. Additionally, body mass was significantly associated

with the development of acute symptoms. Hepatocellular damage was

noted in nurses employed on an oncology unit. This symptom was

associated with the employee’s duration of work exposure and the

volume of handling.9

The main role of nurses in the field of oncology is

chemotherapy administration which is sensitive domain in oncology

nursing where little negligence or mistake may lead to adverse

consequences for patients, staff and environment. Literature

reveals that, medication errors in chemotherapy are a common

(44%) incidence due to lack of specific knowledge and training of

the staff in chemotherapy, prescription, preparation and

administration. This lacking of knowledge and training of the

staff leads to fatal incidences such as over dose of

chemotherapy, wrong calculations of drugs, wrong route of

transfusion which sometimes result in patient’s death. 10

A study on chemotherapy standard order form: preventing

errors was carried out to describe the development and

implementation of one approach to standardize and document

chemotherapy orders for patients in the acute-care settings. To

avoid errors in ordering, dispensing, and administering

chemotherapy that may have the potential for serious adverse

patient outcomes, a standardized order sheet was developed to

consistently document information regarding chemotherapy ordering

and administration throughout the hospital. Each component of the

form is essential in promoting safety and efficiency in the

chemotherapy ordering and administration process. A standardized

approach dramatically improved ordering, dispensing, and

administering chemotherapy. Multidisciplinary verification and

documentation of dose and schedule helps reduce chemotherapy-

related errors.11

While handling chemotherapy drugs and other potent or

hazardous drugs for their patients, nurses must be extremely

careful not to ingest them in any quantity. The National

Institute for Occupational Safety and Health (NIOSH) has released

an alert outlining the risks of handling chemotherapy drugs for

nurses and millions of other health workers. People who handle

chemotherapy drugs at any point from manufacture to patient

dosing and administration are at risk. In a public alert, NIOSH

estimates more than five million workers could be exposed through

various activities. Nurses and other workers are exposed through

prolonged contact with vial exteriors, counting out doses,

crushing tablets, priming intravenous sets and handling

contaminated clothing or waste, among other practices. Handling

chemotherapy drugs can lead to relatively mild symptoms, like

skin rashes. In other cases, adverse reproductive events and

cancer have been linked to exposure.5

The intravenous applications that have been used widely can

lead to some complications such as extravasation, ecchymosis,

hematoma and phlebitis. The extravasation is one of these

complications. Extravasation leads to some undesirable happenings

such as prolonged times of hospitalization of the patients,

unnecessary diagnostic procedures and even unnecessary

treatments, stress effects on the relatives of patients, extra

workload for health staff and the economic loss as well as to

threatening the lives of patients. It is important for the health

professionals, who are responsible for managing of intravenous

applications, to know the drugs that cause tissue injury and take

the necessary measures to prevent extravasation. Therefore, this

article defines the pathogenesis of extravasation, types,

symptoms, and evidence-based management.12

Cancer nursing requires a clinical knowledge of the

disease and its treatment as well as the skills to care for and

support clients and their families.5

Over the last decade concerns about the hazards of handling

chemotherapeutic agents increased as various studies were

published. Analysis of these data suggest possible carcinogenic,

teratogenic and mutagenic risk for health professionals

(predominantly nurses and pharmacists) that handle these drugs.9

Some studies have shown an increased in the number of

people receiving chemotherapy. Current treatment regimens that

include hazardous drugs are more complicated than those employed

in the past. Many regimens include high-dose therapies and use

of multiple drug combinations. While these newer therapies have

significantly improved cancer survival rates, preparing more

drugs and use higher doses of drugs will likely increase workers

exposure to these hazardous drugs.10

An intimate knowledge of the pharmacology and side effects of

each agent, as well as their interactions with one another, is

essential for their use.11 Rapid advancement of medical science

leading to specialization and expectation of improved quality of

hospital care, places an increase in the demand for nursing

services. Due to the changing nature of health care system,

nursing is also undergoing dynamic alteration.12

Most studies demonstrated occupational exposure to hazardous

drugs can occur when safe handling measures fail or when they are

not properly used. Exposure may occur during drug preparation,

transport or administration during the disposal process when

handling patient excreta, and in the event of spills.13

Chemotherapy drugs represent a significant health risk to

healthcare personnel. Such drugs have been found to be

carcinogenic, to cause chromosomal damage and may also cause

damage and may also cause damage to normal skin and necrosis of

compromised skin. The most common exposures are the result

inadvertent ingestion a drug on food, inhalation of drug dusts or

droplets or direct skin contact. Proper training and the use of

personal protective equipments are critical to ensure the safety

of health care workers who handle chemotherapy drugs.14

A study was conducted on “Risk of handling injectable

neoplastic agents” in America. Health care personals, described

physical complaints like skin, mucus membrane and eye irritation,

light headness, facial flushing, hair loss, nausea experienced

following the preparation of antineoplastic drugs.15

Some studies demonstrated that chemotherapy drugs attack

reproducing cells, they cannot differentiate between normal

tissues that are replacing worn-out cells and targeted cancer

cells. The normal cells will be damaged by chemotherapy along

with cancer cells which results in side effects.16

The investigator had exposure to many staff nurses, after

the administration of the cancer chemotherapeutic drugs who were

manifested with skin rashes, itching, dyspnoca etc. The unsafe

handling of the of the drugs is the major cause for these

complaints.The above studies suggest that if appropriate

training, utilization of effective equipment and supplies, and

strict compliance with detailed policies and procedures provides

the best approach to reducing the potential health risks of

occupational exposure to hazardous drugs. Keeping in veiw the

above fact, the investigator planned to conduct the planned

teaching programme on student nurses after assessing their

knowledge on the safe handling of cancer chemotherapeutic drugs

and its side effects. The investiogator also found that this

study will help the student infuture to do the practice in

healthcare effectively and improve their knowledge on the safe

handling of chemotherapeutic drugs.

Cancer nursing requires a clinical knowledge of the disease and

its treatment as well as the skills to care for and support

clients and their families.5

Over the last decade concerns about the hazards of handling

chemotherapeutic agents increased as various studies were

published. Analysis of these data suggest possible carcinogenic,

teratogenic and mutagenic risk for health professionals

(predominantly nurses and pharmacists) that handle these drugs.9

Some studies have shown an increased in the number of

people receiving chemotherapy. Current treatment regimens that

include hazardous drugs are more complicated than those employed

in the past. Many regimens include high-dose therapies and use

of multiple drug combinations. While these newer therapies have

significantly improved cancer survival rates, preparing more

drugs and use higher doses of drugs will likely increase workers

exposure to these hazardous drugs.10

An intimate knowledge of the pharmacology and side effects of

each agent, as well as their interactions with one another, is

essential for their use.11 Rapid advancement of medical science

leading to specialization and expectation of improved quality of

hospital care, places an increase in the demand for nursing

services. Due to the changing nature of health care system,

nursing is also undergoing dynamic alteration.12

Most studies demonstrated occupational exposure to hazardous

drugs can occur when safe handling measures fail or when they are

not properly used. Exposure may occur during drug preparation,

transport or administration during the disposal process when

handling patient excreta, and in the event of spills.13

Chemotherapy drugs represent a significant health risk to

healthcare personnel. Such drugs have been found to be

carcinogenic, to cause chromosomal damage and may also cause

damage and may also cause damage to normal skin and necrosis of

compromised skin. The most common exposures are the result

inadvertent ingestion a drug on food, inhalation of drug dusts or

droplets or direct skin contact. Proper training and the use of

personal protective equipments are critical to ensure the safety

of health care workers who handle chemotherapy drugs.14

A study was conducted on “Risk of handling injectable

neoplastic agents” in America. Health care personals, described

physical complaints like skin, mucus membrane and eye irritation,

light headness, facial flushing, hair loss, nausea experienced

following the preparation of antineoplastic drugs.15

Some studies demonstrated that chemotherapy drugs attack

reproducing cells, they cannot differentiate between normal

tissues that are replacing worn-out cells and targeted cancer

cells. The normal cells will be damaged by chemotherapy along

with cancer cells which results in side effects.16

The investigator had exposure to many staff nurses, after

the administration of the cancer chemotherapeutic drugs who were

manifested with skin rashes, itching, dyspnoca etc. The unsafe

handling of the of the drugs is the major cause for these

complaints.The above studies suggest that if appropriate

training, utilization of effective equipment and supplies, and

strict compliance with detailed policies and procedures provides

the best approach to reducing the potential health risks of

occupational exposure to hazardous drugs. Keeping in veiw the

above fact, the investigator planned to conduct the planned

teaching programme on student nurses after assessing their

knowledge on the safe handling of cancer chemotherapeutic drugs

and its side effects. The investiogator also found that this

study will help the student infuture to do the practice in

healthcare effectively and improve their knowledge on the safe

handling of chemotherapeutic drugs.

6.2: REVIEW OF LITERATUREReview of literature is defined as board comprehensive in

depth systematic and critical review of scholarly

publications in particular topic . The purpose of review of

related literature was to gain an insight in to various

aspects of the problem under study such as design, methods,

instruments, measures and techniques of data collection that

may prove useful in the proposed project.

The literature review is divided into four sections

Section A – literature review on handling of

chemotherapeutic drugs and its side effects

Section B- literature review on knowledge on safe handling

of chemotherapeutic drugs among nurses

Section C- literature review on skill on safe handling of

chemotherapeutic drugs among nurses

SECTION A: LITERATURE REVIEW ON HANDLING OF

CHEMOTHERAPEUTIC DRUGS AND ITS EFFECTS A descriptive study on Prevention and Management of

Extravasation of Cytotoxic Drugs revealed that extravasation of

certain cytotoxic agents during peripheral intravenous

administration may cause severe local injuries. Most

extravasation can be prevented with the systematic implementation

of careful administration techniques. However, the management of

this complication, the aim of which is to prevent progression to

tissue necrosis and ulceration, remains an important challenge in

the care of cancer patients. Empirical guidelines recommend the

use of topical Dimethylsulfoxide and cooling after extravasation

of Anthracyclines or Mitomycin, locally injected Hyaluronidase

after extravasation of Vinca alkaloids, and locally injected

sodium thiosulfate (sodium hyposulfite) after extravasation of

Chlormethine (mechlorethamine; mustine). Plastic surgery may be

necessary when conservative treatment fails to prevent

ulceration. The possibility of late local reactions must also be

considered in the management of patients receiving

chemotherapy.17

A case report on Extravasation: a dreaded complication of

chemotherapy shows that extravasation is a severe complication of

chemotherapy. It is defined either as the escape of a

chemotherapeutic agent from a vessel into the surrounding tissues

by leakage or as an involuntary injection of a drug into the

tissues. The frequency of extravasation in adults is considered

to be between 0.1% and 6%.The severity of tissue injury is

dependent on the type and concentration of the chemotherapeutic

agent and the quantity injected. Prevention of extravasation can

be done by adequate guidelines of chemotherapy administration and

training of nurses is of the utmost importance. 18

The cross sectional survey on Patients' perspectives and

safe handling of oral anticancer drugs at an Asian cancer centre

was conducted, the interviewer-administered survey was undertaken

at the outpatient pharmacy. Eligible patients had received at

least one cycle of oral anticancer agent treatment or had been

taking oral anticancer agents continuously for 3 months. The

majority of the patients (94.2%) reported no difficulties in

adherence to their oral anticancer treatment regimens. Forty per

cent of patients reported habitually washing their hands after

administering their anticancer drugs. None of the patients,

except two patients receiving Capecitabine, indicated that they

habitually used gloves to handle their oral anticancer

medications. However, this survey demonstrated the need to

improve patients' understanding of the requirements for storage,

handling and safe administration of oral anticancer drugs. As the

nurses are responsible for providing education , the nurses

should be educated first in order to improve patients’ safe

handling of drugs.19

An analytical cross sectional study on Health Hazards among

Oncology Nurses Exposed to Chemotherapy Drugs consists of a study

group and a control group of nurses. The study group included 35

oncology nurses who were involved in direct patient care and were

exposed to chemotherapeutic drugs during their preparation and

administration. The control group consists of 29 nurses who were

involved in direct patient care without being exposed to

chemotherapeutic drugs. It was found that health hazards among

the study group and controls were: abortions (31.4% vs 10.3%),

infertility & sub-fertility (14.3% vs 3.4% ), premature labour

(14.3% vs 17.2%), soft tissue injuries due to spills & splashes

(14.3% vs 0.0%), and developmental and behavioural abnormalities

among the children of the nurses (8.6% vs 3.4%). Urine samples

from study nurses were more mutagenic than controls (40% vs

10.3%). Risky behaviour among study nurses included: eating food

in drug handling areas (45.7%), use of improper place for

preparing and handling cytotoxic drugs, expelling air from

syringes filled with drugs, needle stick injuries, unsafe

handling of contaminated material and unsafe cleaning of spills.

Only 22.9% of the study nurses attended a training program about

occupational health and safety and 8.6% of them mentioned that

there are nursing care guidelines for procedures for dealing with

patients receiving cytotoxic drugs as well as presence of in-

service training programs. There was poor use of protective

equipment in the study group.20

A study on Chromosomal aberrations in peripheral lymphocytes

of nurses and physicians handling antineoplastic drugs shows that

the frequencies of structural chromosome aberrations of persons

occupationally exposed to antineoplastic drugs without adequate

protection were measured in peripheral blood lymphocytes of 106

persons from five oncological units and in an adequate control

population. The observed chromosomal aberration frequencies were

3.3 ± 0.1 aberrations per 100 cells in the exposed group and 0.6

± 0.1 aberrations per 100 cells in the controls. Chromosomal

aberration frequencies were not correlated with age, duration of

exposure and smoking habits. The results stress the necessity to

protect hospital staff against the potential risk related to the

handling of antineoplastic drugs. 21

A study on Leukemia and reproductive outcome among nurses

handling antineoplastic drugs consists the study group, female

nurses who potentially had been exposed to antineoplastic drugs

through their work and internal control group of about double the

number of potentially exposed nurses were nurses employed in the

same period in other departments in the same hospitals. It shows

that the crude odd ratio miscarriages among those handling

antineoplastic drugs during pregnancy compared with the control

group was 0.76 (95% Confidence interval 0.38-1.43). The analysis

by exposure level showed a significantly increased risk among

those in the low exposure category. The crude odd ratio for

malformations among those handling antineoplastic drugs during

pregnancy compared with the control group was 1.02 (95%

Confidence Interval 0.47-2.06). Inclusion of all nurses employed

in oncology departments, whether exposed or not, changed the Odd

Ratio to 1.00 (95% Confidence Interval 0.52-1.85).

Standardization according to the age of the mother changed the

risk estimate from 1.02 to 0.99 only. There were no clusters of

specific malformations. The mean birth weight among children live

born to mothers handling Antineoplastic drugs during pregnancy

was 3397 g compared with 3455 g in the control group. The Odd

Ratio for low birth weight according to this definition among

those exposed to Antineoplastic Drugs was 1.06 (95% Confidence

Interval 0. 42-2 .67). The number of observed cancer cases (14)

was close to the expected (11.69) corresponding to an Risk Ratio

of 1.20. The only significantly increased site was lymphatic and

haematopoietic tissue where the increased risk was due to two

cases of leukaemia, giving an Risk Ratio for leukaemia of 10.65

(95% C confidence Interval 1.29-38.5).22

A one year prospective study on Cancer chemotherapeutic

error in hospitalized patients: Attributable damages and extra

costs was conducted in hospital detecting medication errors at

every step of the anticancer chemotherapy use process. A costs

analysis was performed by simulation of potential hospital stays

and valued at the complete hospital cost of the corresponding

diagnosis related groups. Prescription errors represented 91% of

errors followed by pharmaceutical errors (8%) and administration

errors (1%). A statistically significant relationship was found

between the rate of medication errors and month of the year (p =

0.001). May and January were the months most at risk of errors,

while October and November were the least. In total, 13.4% of

avoided errors would have caused a temporary injury, 2.6% a

permanent damage and 2.6% would have compromised the vital

prognosis of the patient (including 4 to 8 potential deaths). If

not avoided, 216 additional hospital days would have been

necessary. Thirteen medication errors reached the patient without

damages except two patients, needing reinforced monitoring. This

study demonstrates that major medication errors take place in

hospital but that a dedicated control quality system allowed

capturing most of them before they reach the patient. Potential

consequences for patients and cost of medication errors justify

the development of preventive actions. Thus, one of the

preventive aspects is preventing administration errors which can

be done by educating the nurses through various educational

programs.23

A study on Preventing Vincristine Sulfate Medication Errors

showed that describe three types of medication errors associated

with its use, and suggest strategies for vincristine sulfate

medication error prevention. Medication errors involving

vincristine sulfate include over dosage (wrong dose), name

confusion (wrong drug), and incorrect administration (wrong

route).Vincristine medication errors are preventable errors that

usually result in serious patient harm and often are lethal.

Nurses need to be aware of the types of medication errors that

can occur with chemotherapy agents and be familiar with clinical

signs and symptoms associated with these errors. Education should

be provided to nurses for proper handling of drugs so that they

can promote patient safety by implementing specific strategies to

prevent vincristine medication errors.24

The above studies show that improper handling of

chemotherapeutic drugs causes harmful effects to both patients

and the nurses who handle them. Extravasation, necrosis ,

ulceration are the challenges infront of health personnel to be

prevented in order to reduce the complications and extra burden

to economy. The nurses are at risk for side effects such as

infertility, preterm labour, leukemia as well as chromosomal

changes. Health care professionals including nurses should be

aware of medicine errors and specific strategies to be developed

to prevent it.

SECTION B: LITERATURE REVIEW RELATED TO KNOWLEGDE ON

SAFE HANDLING OF CHEMOTHERAPEUTIC DRUGS AMONG NURSES A study on Knowledge, Attitude and Safe Behaviour of Nurses

Handling Cytotoxic Anticancer Drugs suggests that the level of

knowledge of the nurses concerning antineoplastics was not

satisfactory. Findings for nurses’ safety behaviour and usage of

recommended health safety measures showed that, notwithstanding

the rules and regulations pertaining to chemotherapeutic drugs,

nurses did not comply with them fully. In service training is a

very effective tool to increase the level of knowledge. This

study also revealed the necessity for improvement of the

working environment and the availability of appropriate

protective equipment.25

A survey on knowledge assessment and information needs of

oncology nurses regarding in patient medication was conducted to

determine how nurses master medications prescribed to their

patients and problems nurses may have with prescribed drugs and

identify possible support tools. About ninety four percentages of

dosage were familiar to participants. The problems nurses having

related to medications were, in order of frequency, difficulties

with notions of therapeutic equivalents and generic drugs (89%),

storage condition (81%) and dilution, reconstruction and

administration methods (79%). However, side effects,

contraindications, and drug-drug interactions were not adequately

identified. Nurses reported facing problems mainly related to

drug administration, drug storage, and generic drugs and their

therapeutic equivalence. Nurses need to be made aware regarding

handling of drugs by providing education and multiple tools are

in development to help nurses in these areas. 26

A study on The influence of nurses knowledge,

attitudes and health beliefs on their safe behaviour

with cytotoxic drugs was conducted. Sixty‐one nurses

participated in the study, 31 hospital‐based nurses

daily exposed to cytotoxic drugs for the last 5 years.

A gap was found between the nurses' knowledge and their

actual behaviour concerning the potential risks of

cytotoxic drugs and their use of protective measures

(p< .005). Significant correlations were found among

the components of the extensive Health Belief Model

(perceived susceptibility, barriers, benefits and self‐

efficacy). The study's findings support the need to

promote primary prevention by providing a safe

environment for the employee by means of education,

training with regard to safety measures, clear policy,

written guidelines and their enforcement. 27

A single group pre-test post- test study on

Assessment of knowledge, skill and attitude of oncologynurses in chemotherapy administration in tertiary hospital shows

that The information regarding participants’ working experience

shows that the majority 18 (51%) had more than 10 years of

working experience as a general nurse, while 16 (46%) had less

than 5 years of work experience as a chemo nurse, indicating that

the majority of the study participants 19 (54%) had less work

experience as chemo nurse. Results of the study showed that all

participants were female, majority (80%) were undergraduates and

have less working experience as chemo nurse, and only one third

(30%) were oncology trained, the mean scores of knowledge were

calculated by Cochran’s Q test. The knowledge scores have

significantly increased with ‘educational training’ (p value <

0.001) and the results of the study illustrate value of the

participants attitude was 58.2, which was higher than the other

two components (knowledge and skills). The difference in the

attitude of the nurses was not found to be statistically

significant in repeated measure of ANOVA. 10

The above studies revealed that knowledge of nurse regarding

handling of chemotherapeutic drugs is less and knowledge is to be

improved by conducting inservice education, other educational

programmes written guidelines and making clear policies.

SECTION C: LITERATURE REVIEW RELATED TO SKILL ON SAFE

HANDLING OF CHEMOTHERAPEUTIC DRUGS AMONG NURSESA cross sectional study on The handling of anticancer drugs

shows that only seven (58%) of the 12 hospitals investigated, had

a written policy for handling such hazardous chemicals. Staff

nurses were involved in preparation of cytotoxic drugs in three

(25%) hospitals, while domestic staff were involved in cleaning

up spillage in five (42%) hospitals. Administration of these

drugs was mainly carried out by nursing (42%) or both staff. The

site of preparation was considered unsuitable in five hospitals

(42%), due to either lack of essential equipment such as vertical

laminar flow cabinet (33%) or use of the site for preparing other

drugs gloves were used during preparation in all of these

hospitals, while eye spectacles and surgical face masks were used

in six (50%) hospitals, and gowns or aprons were used in 9 (75%).

Special trays or absorbent sheets for preparation were used in

75%, while a special pad to break open ampoules was used in 50%

of investigated hospitals. A vertical laminar flow cabinet was

used in 67%, and Luer lock syringe fittings in 75%. Only in one

hospital was air expelled from syringes into a special pad. The

study revealed serious inadequacies in equipment and expertise in

handling cytotoxic agents in some of the investigated hospitals.

These range from absence of written policies to lack of essential

facilities and proper training and practice. Although some effort

has been made to promote the standard of safety handling of

cytotoxic drugs.28

A descriptive study on Cytotoxic drug spillages among

nursing personnel working in the chemotherapy administration

areas was conducted to determine the patterns of the cytotoxic

drug spillages & the exposure of the nurses to these spillages.

An observational assessment was carried out in the Chemotherapy

administration areas (Radiotherapy Ward, Radiotherapy and Medical

Day Care Rooms)at a tertiary care hospital. During one month

observation, 77.3% of the nurses experienced small spills (< 5ml

or 5 gms). The common site of the spillage for more than half

(52.9%) of the subjects was surface of preparation of the drug

and 47% experienced spillage over both surface of preparation and

the gloves worn by them. The prevalence of spill per person in

all the three research settings was 1.3, 2 and 3.6 respectively

for Radiotherapy Ward, Radiotherapy and Medical Day Care

Chemotherapy rooms. The mean (no. of spillages) ± S.D = 2.53 ±

1.74. The comparison of difference in terms of spills occurrence

in three research settings using Kruskal Walli's test. A

significant difference was observed in occurrence of spills among

three research settings with Kruskal Walli's P value of

0.008.When three Research settings were evaluated for significant

difference among themselves using post hoc analysis, it was found

that subjects in Medical Day Care experienced significantly

higher spills than the subjects working in Radiotherapy Ward and

Radiotherapy Day Care with P value of 0.006 and 0.051. Results

suggest that drug spills are common in chemotherapy

administration areas. Guidelines to manage the cytotoxic drug

spills to be displayed in the unit and a "chemotherapy spill kit"

to manage cytotoxic spills should be made available in all the

chemotherapy administration areas. 29

The above studies show that the skill of nurses handling

cytotoxic drugs is inadequate spills in the administration site

should b properly handled by proper guidelines and making

available chemotherapy spill kit.