Safe Administration Of Intracerebrospinal Fluid Chemotherapy (Icc).

229 Background: ICC administration, which includes intrathecal and intraventricular routes, is a complex procedure that involves staff from different disciplines. ICC administration errors are rare, yet potentially fatal. Since 1968, more than 55 cases of ICC administration errors have been documented, but the incidence is suspected to be higher because of underreporting. Little unified action has occurred despite alerts issued by the Joint Commission on Accreditation of Healthcare Organizations and World Health Organization. We have taken a multidisciplinary approach to address this issue.We identified two problems that could potentially lead to ICC errors: the lack of a formal institutional training/certification program and a comprehensive institutional safe ICC administration policy. Our Hematology-Oncology Fellowship Program along with Pharmacy and Nursing at the University of Connecticut Health Center (UCHC), created a multidisciplinary work group whose purpose is to create a comprehensive institutional policy and training program for disciplines involved in the administration of ICC.The safeICC administration policy has been finalized and presented for approval. Creation of the training program is in progress and will be a part of the educational Core Curriculum of the Fellowship Program. Fellows will be required to demonstrate competency in lumbar and Ommaya reservoir puncture using simulation training on mannequins. Computer-based training with classroom review and testing will be required for all disciplines involved with ICC and will include safe preparation, delivery, handling, verification, administration of ICC, and identification of potential complications. Annual certification will be required.The lack of a formal ICC administration policy and training can lead to catastrophic errors. Development of an institutional policy and training program has heightened awareness of potential sources of ICC administration errors at UCHC and will serve as a mechanism for assessing quality care in the future. We believe the establishment of such a policy and definition of training should be part of the general ASCO/ONS guidelines for safe administration of chemotherapy.