Incidents presented according to the main defence (as in figure 1) breached
| Defence | Number of reports |
|---|---|
| Administration only in designated centres | 0 |
| Only those on local register can prescribe, dispense, issue, check or administer intrathecal (IT) chemotherapy | 0 |
| IT chemotherapy on separate prescription with accompanying checklist and audit trail | 1 |
| Intravenous (IV) and IT chemotherapy separated in time | 15 |
| 1. Administered at separate times—IV then IT | 6 |
| 2. Signature to confirm all IV chemotherapy for that day given, before IT released to the doctor who will administer it | 9 |
| IV and IT chemotherapy separated in location | 7 |
| 1. Separate storage in pharmacy and ward areas, with IT doses in a dedicated locked fridge | 5 |
| 2. Separate storage in pharmacy and ward areas, with IT doses in a dedicated locked fridge | 5 |
| 3. Separate transport of IT in distinctive container | 1 |
| 4. Administration in separate clinical areas | 1 |
| IV and IT chemotherapy differentiated in appearance | 6 |
| 1. IV vinca alkaloids for adults and adolescents prepared in minibags, not syringes | 1 |
| 2. Labelling of medication with route of administration printed in bold ‘for intrathecal use only’ and ‘for intravenous use only’ | 5 |
| Under normal circumstances, administered during working hours only | 0 |
| Administration checks | 0 |
| Other | 6 |
| TOTAL | 35 |
Bold numbers represent main categories; italic numbers represent sub-categories of these.