Dosing


chemotherapy doses extremely time consuming.


Service reconfiguration


The availability of prefilled syringes can lead to new and efficient ways of working. For example, at the Norfolk and Norwich University Hospital a system was put into place whereby a stock of prefilled syringes is retained on the chemotherapy unit. Chemotherapy nurses were trained to follow an approved protocol to assemble all the prefilled syringes required for the day against their respective prescriptions once the unit opened each morning; these would then be checked by an approved pharmacy checker before being released for administration. This proved to be an efficient system that allowed patients to be treated while waiting for other chemotherapy doses to be made and delivered from the pharmacy.4


Reduced wastage


The potential for wastage is also reduced. Chemotherapy doses prepared in unlicenced aseptic dispensing units that do not have a ‘specials’ licence are limited to a maximum expiry period of seven days.5


If a patient-specific dose of


chemotherapy is prepared in such a unit and the treatment is subsequently cancelled, there is a high probability that the dose will expire before it can be re-used for another patient.


As prefilled syringes purchased from a manufacturer with a ‘specials’ licence will usually have a shelf-life of several


the cost per unit dose is likely to be higher than for those produced internally as patient-specific doses. This is inevitable because the manufacturer will need to charge for overheads as well as the base drug cost and mark-up. However, this additional cost might not be considered significant in some pharmacies where purchasing prefilled syringes is necessitated by capacity issues that otherwise would require employing additional staff.


Furthermore, because there are several large-scale commercial aseptic manufacturers in the UK, pricing is kept at a competitive level. Certainly, procurement pharmacists have the ability to tender different manufacturers to supply the more common chemotherapy agents available as prefilled syringes either as individual hospitals or, even more powerfully, on a regional basis covering a large number of hospitals. Besides cost, lead times, shelf-life, presentation and other quality factors will be taken into consideration during the tendering process.


Waste


Prefilled syringes can help reduce wastage but care is required to ensure that the syringes themselves are not wasted by not being used before their expiry date. However, as the chemotherapy agents most commonly available as prefilled syringes usually have a shelf-life of at least three months, this is rarely a problem. Providing a stock rotation


“Prefilled formats have several advantages, including convenience and ease of supply in pharmacy manufacturing services”


months, the potential for wastage is significantly reduced.


Reduced wastage was demonstrated by an audit conducted at a peripheral outpatient clinic in Birmingham, which found that 13.5% of cycles of chemotherapy for breast cancer were deferred. When these were supplied as prefilled syringes from a centralised compounding unit, all the unused doses could be re-issued, resulting in significant cost savings.6


Disadvantages of prefilled syringes Cost


When prefilled syringes are purchased from an external specials manufacturer,


system is put in place and the range of syringe sizes for each agent is kept to a minimum and selected carefully, the risk of wastage is very low.


Errors


It is reasonable to assume that using prefilled syringes is likely to reduce the risk of errors occurring during their supply, compared with the preparation of individualised chemotherapy, which involves a number of stages. However, errors do still occur and they are usually different and attributable to factors such as inadequate training, distractions and interruptions.7


Errors that may be encountered include supplying expired


syringes, supplying incorrect strengths or the wrong chemotherapy agent.4 Error rates can be minimised by ensuring that all staff involved in the supply of prefilled syringes are well trained and that the syringes are dispensed and checked in a suitable environment. Where multiple syringes of a different strength are needed to make up a single dose, tables may be beneficial (see Table 2). Also good stock rotation and the segregation of agents with a similar appearance (for example, doxorubicin and epirubicin) can also help.


Conclusions


Using prefilled syringes to supply chemotherapy doses can be extremely beneficial if well implemented. Prefilled formats present several advantages, particularly with regards to convenience and ease of supply in pharmacy manufacturing services where capacity can be an issue. Disadvantages such as the potential for waste and introducing different types of errors can be kept to minimum by ensuring staff are adequately trained and robust procedures for supplying syringes are implemented. Additional procurement costs can also be reduced or balanced against other potential savings. ●


References 1. Medicines and Healthcare products Regulatory Agency. MHRA Guidance Note 14: The Supply of Unlicensed Relevant Medicinal Products for Individual Patients. London: Medicines and Healthcare products Regulatory Agency, 2008.


2. Plumridge RJ, Sewell GJ. Dose-banding of cytotoxic drugs: A new concept in cancer chemotherapy. Am J Health Syst Pharm 2001;58:1760–74.


3. National Patient Safety Agency. Rapid Response Report Using Vinca Alkaloid Minibags (Adult/ Adolescent Units) NPSA/2008/RRR004. London: Department of Health 2008.


4. Small M et al. Nurse dispensing of prefilled chemotherapy syringes in an oncology day unit. Pharm Pract Sept 2009:90–93.


5. Quality Assurance of Aseptic Preparation Services. Beaney AM (editor). 4th edition. Pharmaceutical Press. London 2006.


6. Baker JP, Jones SE. Rationalisation of Chemotherapy Services in the University Hospital Birmingham National Health Science Trust. J Oncol Pharm Pract. 1998;4:10–14.


7. Bateman R, Donyai P. Errors associated with the preparation of aseptic products in UK hospital pharmacies: Lessons from the National Aseptic Error Reporting Scheme. Qual Saf Health Care 2010;19:1–6.


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