No abstract

Although the active pharmaceutical ingredient remains constant, the excipients used will vary according to the manufacturer. This case report is of spuriously raised serum creatinine due to an excipient in one particular intravenous dexamethasone formulation. A patient had three serum creatinine measurements of 102, 369 and 91 mmol/L over a four-hour period. The second result was believed to be spurious and appropriate investigations were instigated. The patient had received dexamethasone intravenously between the first and second blood samples. This was administered as a bolus via a cannula in the dorsum of the hand, and the blood sample was taken by venepuncture of the antecubital fossa of the same arm approximately five minutes later. The dexamethasone used (Hospira UK Ltd) contained creatinine at a concentration of 70,720 mmol/L, with a total of 170 mmol of creatinine given to the patient. Assuming a volume of distribution of 40 L in a 70-kg man, an increase in serum creatinine of 4 -5 mmol/L would be expected once equilibrated. It is thought that the serum creatinine result observed was a consequence of the creatinine excipient in the dexamethasone not having completely distributed throughout the body and still being at relatively high concentrations within the limb into which it had been administered. Intravenous dexamethasone can lead to spurious creatinine results, not due to analytical interference but rather the analytically correct measurement of creatinine added as an excipient. This case clearly demonstrates the impact preanalytical factors can have on the accuracy of results.

Summary A survey of all hospital pharmacies in the former North Western Regional Health Authority has revealed that hospital personnel continue to prepare cytotoxic drugs in suboptimal conditions, despite the widespread introduction of pharmacy cytotoxic reconstitution services. Other concerns include the lack of formal training for medical staff in the administration of these agents and the frequent absence of written procedures for dealing with extravasation and chemotherapy errors.Keywords: audit; delivery of cancer chemotherapy A series of well-publicised accidents in which patients have died as a result of errors in the administration of cytotoxic agents (Sunday Times, 1993;Zaragoza et al., 1995) are a reminder that these drugs remain among the most toxic substances commonly administered.Occupational exposure to cytotoxic drugs has been associated with adverse pregnancy outcomes Selevan et al., 1985;McDonald et al., 1988;Stucker et al., 1990), an excess risk of leukaemia (Skov et al., 1990(Skov et al., , 1992 and case reports of bladder (Levin et al., 1993) and nasopharyngeal carcinoma (Gabriele et al., 1993). An Australian pharmacist recently won industrial compensation when he presented with duodenal cancer after preparing cytotoxic drugs in a faulty biohazard cabinet that had repeatedly failed safety checks (Hudson, 1990;Carden, 1991;Rodriguez and Yap, 1991).Although the absence of robust measures of exposure and the need to ascertain rare outcome events make it difficult to precisely quantify the risk to healthcare personnel, most countries have introduced formal guidelines (Health and Safety Executive, 1983; Pharmaceutical Society Working Party, 1983; OSHA, 1986;Skov, 1993) that aim to reduce staff exposure to antineoplastic drugs to the lowest practicable level. The Joint Council for Clinical Oncology (JCCO) has also recently published a series of recommendations that clarify the responsibilities of medical staff for the prescribing and administration of cancer chemotherapy (Table I) (JCCO, 1994).We now report a regional survey, the aim of which was to describe the delivery of cancer chemotherapy before the dissemination of the JCCO guidelines (JCCO, 1994). Our objectives were to report on current practices relating to the prescribing, preparation and administration of cancer chemotherapy. MethodA postal questionnaire, prepared and piloted in consultation with medical oncologists and hospital pharmacists, was distributed to all hospital pharmacies in the former North Western Regional Health Authority in July 1993. Construction of the questionnaire was informed by a draft of the JCCO (1994) guidelines and previous published guidelines (Health and Safety Executive, 1983; Pharmaceutical Society Working Party, 1983) Pharmacy cytotoxic reconstitution services were available on site in 21 of the 29 units (72%). Of the eight hospitals with no on-site facility, the services of an outside hospital were used in four and drug preparation took place on the ward or outpatient department in the remainder. Eve...

SO J. (2010) European Journal of Cancer Care19, 35–39
Improving the quality of homecare oral chemotherapy services There has been a plethora of oral chemotherapeutic agents introduced over recent years. For hospital pharmacies this has meant unprecedented activity. At the same time there is pressure to meet waiting time targets and to improve patient experience. The Cancer Centre had already used homecare services for trastuzumab (Herceptin) so it seemed reasonable to apply this to selected oral agents. A formal tender resulted in a contract award for homecare. The service has been running successfully for 3 years with imatinib in chronic myeloid leukaemia and in gastro‐intestinal stromal tumour patients. Patients are informed about the homecare supply service in clinic by the nurse or pharmacist, with most patients opting for the service rather than a wait in pharmacy for their prescription. The drug is then delivered by post to the patient's home. We plan to extend the service in the coming months to include a second oral agent, erlotinib for the treatment of non small cell lung cancer. As well as avoiding a patient wait in pharmacy, provision through a homecare company offers a more cost effective way for the Trust to deliver an oral chemotherapy service. By reducing the number of patients arriving in pharmacy for prescriptions, it facilitates the achievement of outpatient waiting time targets and improves the overall patient experience.

Editor-Studies investigating the impact on mortality of socioeconomic and lifestyle factors such as smoking tend to report death rates, death rate ratios, odds ratios, or the chances of smokers reaching different ages.