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Intrathecal SACT assessment questions

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All NHS facilities providing intrathecal chemotherapy treatment must introduce and maintain a register of designated personnel who have been trained and certified competent to prescribe, dispense, check and administer intrathecal chemotherapy.  Individuals placed on the register must demonstrate that they are competent to fulfil their designated role, and have been certified as such.

This SOP describes the training that must be undertaken to fulfil this role.


Authorised personnel/specific staff competencies
  • All staff on the register must be re-accredited every 2 years.  Staff who are not re-accredited will be removed from the register.

  • Every member of staff must read the above material and complete the assessment questions - both core and role specific questions.  All questions must be answered correctly.  A score of less than 100% will require the individual to re-read the essential reading material and repeat the assessment with their assigned trainer. 



The Core General Questions 1-18 must be answered by all staff with reference to the GG&C Intrathecal SACT Policy. In addition the Paediatric Specific Questions 1-9 must be answered with reference to RHC-HAEM-ONC-013 (Policy for Intrathecal Chemotherapy).  In addition to this, clinical pharmacy personnel must also answer the additional set of pharmacy questions at the end of the questionnaire. 

On completion of the questionnaire staff should pass this to their professional lead for intrathecal SACT or designated deputy for marking.

To be deemed competent a score of 100% must be obtained. If a score of less than 100% is achieved, then the policy must be re-read, and the assessment repeated.

All staff must demonstrate competency associated with their specific role for intrathecal SACT before being signed off as competent and their name added or updated on the register.


Further information / exceptions

There are no exceptions to this SOP and deviations are not acceptable.

For further information contact:

  • Prof Brenda Gibson, Consultant Haematologist
  • Karon McDowall, Lead Pharmacist
  • Wendy Taylor, Advanced Nurse Practitioner
Appendix 1: Intrathecal Chemotherapy Assessment Questions
Appendix 2: Sign-off sheet
Editorial Information

Last reviewed: 07 November 2022

Next review: 30 November 2024

Author(s): Wendy Taylor

Version: 9

Approved By: Schiehallion Clinical Governance Group

Document Id: RHC-HAEM-ONC-015