The Leeds Teaching Hospitals NHS Trust

Chemotherapy preparation - the Pharmacy Aseptic unit

This information is provided for those of you, who are curious to know the steps that are needed to prepare your chemotherapy and make it ready for your treatment.

  • A specialist Oncology or Haematology pharmacist orders the intravenous chemotherapy by sending a copy of the prescription to the pharmacy aseptic unit.
  • When an order is received, a set of instructions called a worksheet is produced for each chemotherapy item. This includes specific details of what is being made, who it is for, the ingredients and equipment required and how it should be prepared and stored. The worksheet may be described as a “recipe” for correct preparation of the chemotherapy.
  • A label is produced giving details of the drug, dose, patient, storage conditions and expiry details of the product. Some drugs have a very short expiry once they have been prepared so can only be made on the day of treatment. Many drugs are made in advance wherever possible.
  • Before the chemotherapy is prepared, a check is performed to make sure that all the details on the worksheet match those on the order.
  • The worksheet transferred into the “inner support” area. In this area all of the equipment and raw materials are assembled in a tray and the details are recorded. The contents of the tray are checked to ensure that the correct ingredients have been set up ready for preparation. Staff working in the inner support and clean room areas wear special clothing, hairnets, gloves and shoes to ensure that the unit is not contaminated. The unit also has a special airflow to prevent contamination and is cleaned daily with specialist cleaning products.
  • Once the product is ready for preparation it is transferred into one of our clean rooms. These rooms are supplied with specially filtered air and operate under pressure gradients to ensure that the products we make are protected from contamination. Our highly trained team prepare chemotherapy in a specialist device called an isolator.
  • Once the chemotherapy has been made it is transferred out of the clean room to another area called the release area, where a team of technicians and pharmacists carry out two further checks. In these checks we make sure that the chemotherapy has been prepared according to the worksheet and that the product is suitable for use.
  • The chemotherapy is then packaged up and delivered to the ward where the specially trained nurse will administer it you.
  • Some chemotherapy may be stored in the pharmacy aseptic unit whilst the specialist Oncology or Haematology pharmacist is waiting for blood test results or to resolve queries with doctors or to check any questions with you. Once it has been confirmed that it is safe to give the chemotherapy, the specialist Oncology or Haematology pharmacist will inform the aseptic unit and the chemotherapy will be delivered to the ward.