Standards › Standard 51 › Standard operating procedures (SOPs)
SOP · ONC-SOP-001 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 51.1
At a glance
- Cytotoxic and other hazardous drugs are prepared, given and disposed of under the safe-handling standard in this procedure.
- The right personal protective equipment is worn for each task, and its use is checked (ONC-REG-001).
- Spill kits are stocked and staff are trained in their use.
- Waste is segregated and disposed of as hazardous waste.
- Stop and get help straight away if: a cytotoxic drug is prepared or given without the required protective equipment.
1. Purpose
To make sure cytotoxic drugs are handled, given and disposed of in a way that protects staff and patients (51.1).
2. Scope
| Applies to | Clinical and support staff in the hospital |
| Locations | All wards, clinics and departments of the facility |
| When | Whenever the activity described is carried out |
| Does not apply to | Activities covered by another document listed in section 15 |
3. Definitions
| Term | Meaning |
|---|---|
| Clinical lead | The doctor or nurse in charge of the area at the time |
4. Background
Cytotoxic drugs can harm the people who prepare and give them, and the environment. A verified safe-handling standard for preparation, administration and disposal protects everyone.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Oncology pharmacist | Owns the standard and the verification programme | Clinical lead |
| Nurse in charge | Makes sure each task has the right equipment and spill kit | Oncology pharmacist |
6. Materials and equipment
| Item | Requirement | Condition |
|---|---|---|
| Records and forms named in this document | Current version | Checked before use |
7. Safety
- Stop and call for help if a patient is at immediate risk. Do not delay urgent care to complete paperwork.
8. Before you start
- Confirm the forms and equipment named in this document are available and current.
9. Procedure
Step 1. Equip.
- Wear the protective equipment set for each task (preparation, giving and disposal).
Key point: Equipped.
Step 2. Handle.
- Prepare, give and dispose of each drug under this procedure.
- Use the spill kit and report any spill.
Key point: Handled.
Step 3. Verify.
- Check practice at the set interval and record the result (ONC-REG-001).
Key point: Verified.
10. Decision points
- No decision points in this procedure.
11. Special situations
| Situation | Action |
|---|---|
| Out of hours | Follow the same steps. Use the on-call contact on the wall of the area. |
12. Escalation
- Any serious problem goes to the duty clinical lead at once and to the clinical director the same day.
13. Monitoring
| Measure | Target | Frequency | Owner | If not met |
|---|---|---|---|---|
| Preparations with the right protective equipment | 100% | Monthly | Oncology pharmacist | Stop the task until equipped |
| Spill kits stocked on each shift | 100% | Daily | Nurse in charge | Restock at once |
14. Records
| Record | Kept in | Retention |
|---|---|---|
| Record named in this document | Patient record or the area file | the period set by the facility’s records policy years |
15. Training
- Staff are trained in this document at induction and refreshed each year, with a recorded competency check.
16. Related documents
| ID | Title | Use |
|---|---|---|
| ONC-REG-001 | Cytotoxic handling verification register | Register |
| WRK-REG-001 | Training matrix register (existing, reused) | Register |
17. Evidence
| Reference | Note |
|---|---|
| E-006 | ASF Policy Framework v1.2. Adapted. |
| E-009 | ASF Expert Committee consensus. |
18. Change history
| Version | Date | What changed | Approval |
|---|---|---|---|
| 1.0 | the date of approval | First version | set Expert Committee approval |
E-learning for this document
References
- Accréditation Sans Frontières (2026). ASF Policy Framework v1.2. (E-006)
- Accréditation Sans Frontières (2026). ASF Expert Committee consensus on Standard 1. (E-009)