Name of person completing request:
Hospital Trust/Health Board:
Telephone No:
E-mail Address:
1. Does your organisation provide a chemotherapy service – this may include inpatient, outpatient or a community service? 0 Yes 0 No
2. In the past financial year, how many doses of chemotherapy did you deliver? (April 2016 – March 2017)
3. In the past financial year, how many doses of anthracyclines did you administer? (April 2016 – March 2017)
4. In the past financial year, how many anthracycline extravasations have been reported due to chemotherapy? (April 2016 – March 2017)
5. In the past 3 financial years, how many patients have submitted a claim for medical negligence and/or damages against the Trust/Health Board due to an anthracycline extravasation injury?
6. In the past 3 financial years, how much compensation has the Trust/Health Board had to pay to those claimants who have suffered an anthracycline extravasation injury and have been successful in their medical negligence and/or damages case?
7. Does your Trust/Health Board have in place guidelines as to how to recognise and manage an extravasation injury? If not, is this available via your Cancer Alliance/Network or another source? If other, please state source ………………………………………………….
Trust/Health Board Guidelines 0 Yes 0 No If yes, when were they last updated?…………………………………………
8. Does your Trust/Health Board stock or have readily available any of the following extravasation treatments for chemotherapy?
a. Sodium Thiosulfate 0 Yes 0 No If yes, how often used in the past financial year? (April 2016 – March 2017)……………………
b. Hyaluronidase 0 Yes 0 No If yes, how often used in the past financial year? (April 2016 – March 2017)……………………
c. DMSO 0 Yes 0 No If yes, how often used in the past financial year? (April 2016 – March 2017)……………………
d. Dexrazoxane (Savene) 0 Yes 0 No If yes, how often used in the past financial year? (April 2016 – March 2017)……………………
9. In the past 3 financial years, how many annual reconstruction operations have been carried out by the Trust/Health Board due to an extravasation injury?
10. Does your Trust/Health Board’s plastics and/or nursing team have the expertise/core competency to undertake the wash-out/flush-out technique if an extravasation occurs?
0 Yes 0 No
11. If you answered yes to question 10, in the past 3 financial years, how many wash-out/flush-out procedures have been carried out by the Trust/Health Board due to an extravasation incident?
