1. Selection of opportunities for improvement (outline for problem)
Similar to intravenous formulations, oral chemotherapy has the same exposure risks leading to adverse events such as cancer, fertility problems and fetal abnormalities. To minimize occupational safety hazard, we aim to improve safe handling of oral antineoplastic agents among outpatient pharmacy department (OPD) staff at HTAR.

2. Key Measures for Improvement
The key indicator measured is percentage of prescriptions with oral antineoplastic agents handled by OPD staff which comply to safe handling practices. The standard was set at 100% as safety of staff should not be compromised.

3. Process of gathering information
A self-administered questionnaire was distributed to all OPD staff to assess their knowledge on safe handling practices. This is followed by a cross-sectional study over one month for both pre- and post-intervention studies, using a validated audit checklist to identify the compliance of safe handling of oral chemotherapy involving all prescriptions received at OPD during office hours.

4. Analysis and Interpretation
Based on the verification study, only 41% of staff managed to identify more than 50% of the oral antineoplastic agents available in the hospital. Moreover, none of the prescriptions with oral antineoplastic agents handled by OPD staff fully complies to safe handling practices.

5. Strategy for change
The existing work procedure manual was updated to include wearing of chemotherapy-tested gloves during handling of oral antineoplastic agents. Oral antineoplastic agents were segregated at a designated area with chemotherapy-tested gloves provided and clear warning labels on the medication bins. Briefings on safe handling practices were given to the OPD staff. In collaboration with The Occupational Safety and Health Administration, a person-in-charge was appointed at OPD to update list of oral antineoplastic agents and keep it available at all times.

6. Effects of change
The compliance rate to safe handling practices during receiving and storing of medication has successfully achieved 100% in both cycle 1 and cycle 2. On the other hand, the percentage of prescriptions which fully comply to safe handling practices increased from 0% to 32% in cycle 1, and then to 40% in cycle 2. Achievable Benefit Not Achieved (ABNA) was 100% during verification study, 68% in cycle 1 and finally 60% in cycle 2.

7. The Next Step
We will continue to improve and monitor compliance to safe handling of oral antineoplastic agents among all pharmacy staff in HTAR through regular education, enforcement and audit. We also plan to provide education to patients on safe handling and eventually extend our strategies of change to government health clinics in Klang.