Chemotherapy Verification

Identify an RN who is about to give a chemotherapy medication

Which department are you completing this survey for?

Name of the employee observed:

Two person independent check was documented by two MDs (or a NP/PA/Fellow along with one attending), two pharmacists and two chemo-competent RNs
Has patient met “criteria to start” if beginning a new cycle?

(ANC, Platelets, Required observations)
Two RN verified correct day/time for chemo administration, according to roadmap
Two RN verified height/weight/BSA is accurate on roadmap?

  • ht/wt/BSA is not adjusted mid-cycle
Two RNs verified all calculated doses on roadmap are correct
Two RNs verified all drugs/doses on roadmap were compared to the paper orders and match
Two RNs verified order stating “Chemo orders reviewed by provider and approved for administration” in SCM (Not needed for BMT patients)

(Not needed for BMT patients)
Two RNs verified whether pre-hydration was required, co-hydration is required, post-hydration will be required and all fluid orders are in SCM
Two RNs verify all required parameters were met prior to chemotherapy initiation, if applicable?

  • Reviewed by two RNs
Two RNs verified chemotherapy medication against the orders
RN verbalizes potential side effects anticipated for chemotherapy drug being administered
Two RNs verified all supportive care orders are in SCM (leukovorin, Mesna, etc.)
Family received education and handouts for all drugs being given
Two RNs verified correct patient identification, drug, dose, route, rate, volume, time?
Two RNs ensured the line was primed correctly?
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