December 19, 2018

Policies, Procedures and Guidelines Updates – December 2018

By msequeira

The UNM CCC Clinical Operations Committee approved the following policies on Dec. 12, 2018:

UNMCCC Policy on Policies. This policy establishes the framework for the development, approval, dissemination, control and management of University of New Mexico Comprehensive Cancer Center (UNMCCC) policy, procedure, and guideline (PPG) document that apply to ALL UNMCCC workforce.

BMT-022 – Management of Adverse Events, Deviations, Accidents and Complaints Procedure. The Bone Marrow Transplant (BMT) Program follows institutional Patient Safety Intelligence (PSI) Incident reporting system procedure for reporting any occurrences that are not consistent with the routine operation or care of transplant patients. This procedure supplements the institutional procedure to include the management of occurrences related to collection, processing, storage, distribution, or administration of a cellular therapy products.

BMT-008 – Patient Communications Guideline. The guideline outlines triage of Bone Marrow Transplant (BMT) patients during business hours and after hours.

BMT-116 – Discharge Instructions. Provides instructions to patients on recovering after a stem cell transplant.


UNMCCC Clinical Operations Committee approved the following Procedures on Dec. 19, 2018

LUTATHERA. Procedure establishes the procurement, storage, handling and dispensing of Lutetium-177 (Lu-177) dotatate (LUTATHERA®).

Chemotherapy Administration. This policy is to ensure that safety standards are followed for the prescribing, administration, handling and disposal of cancer chemotherapy drugs.

Chemotherapy Ordering. UNMCCC will designate Physicians and other Health Care Providers who can initiate orders and approve Chemotherapy.


All policies, procedures and guidelines for UNM Comprehensive Cancer Center are found in PolicyMedical.

Use PolicyMedical to review the policies above:  http://cancer.unm-

Tags: Clinic, guidelines, Notes, policies, policy, PolicyManager, procedure