Standards › Standard 51 › Standard operating procedures (SOPs)
SOP · ONC-SOP-004 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 51.4
At a glance
- Staff who give vesicant or irritant chemotherapy are trained to recognise early signs of extravasation.
- A written immediate management protocol is followed at the first sign, and the step taken is recorded (ONC-FRM-003).
- The antidote and equipment for management are available at the chair.
- Each extravasation is reviewed (DET-SOP-002).
- Stop and get help straight away if: an extravasation is found and management does not start immediately.
1. Purpose
To make sure extravasation is recognised early and managed at once (51.4).
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
If a drug that damages tissue leaks into the skin during an infusion, it can cause severe injury. Staff who recognise it early and act at once limit the harm.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Oncology nurse | Recognises and starts the management protocol | Oncology physician |
| Oncology pharmacist | Keeps the antidotes and the protocol current | Clinical lead |
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. Recognise.
- Check the infusion site at set intervals for early signs of extravasation.
Key point: Recognised.
Step 2. Stop and manage.
- Stop the infusion and start the immediate management protocol at the first sign.
Key point: Managed.
Step 3. Record.
- Record the steps and times (ONC-FRM-003), and review the event.
Key point: Recorded.
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 |
|---|---|---|---|---|
| Staff giving vesicants trained in recognition | 100% | Yearly | Oncology pharmacist | Withdraw from giving until trained |
| Extravasations managed with the protocol started at once | 100% | Each event | Oncology physician | Review the event |
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-FRM-003 | Extravasation management record | Record |
| 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)