Objective:

assess staff knowledge and implementation of the security protocol in the administration of chemotherapy in the hematology department at the San Jose Hospital, Bogota.

Material and methods:

the implementation was evaluated through checklists in each protocol process and the knowledge evaluation by a15 questions questionnaire.

Reference frame:

hematology department of the San Jose Hospital, Bogota.

Units of analysis:

chemotherapy cycles administered to adult patients with diagnosis of hematologic malignancies.

Participants:

service personnel involved in chemotherapy administration processes.

Measurements:

the patient's demographic characteristics, the incidents of the chemotherapy administration process and adherence to the protocol by the health personnel were described with the medical records. Authors designed the evaluation questionnaire.

Results:

in 291 chemotherapy cycles (129 patients) there were 214 incidents of the chemotherapy administration process out of a total of 4074 possible (5.2%), of which 16 are directly related to the use of the drugs. Adherence to protocol processes ranged from 40.5 to 100%. Staff knowledge had a slight improvement when comparing the two evaluations performed.

Conclusions:

although the expected adherence to the protocol was not achieved, a decrease in incidents was obtained compared to previous institutional studies. A new improvement plan is required to increase adherence and achieve greater impact on patient safety. (Acta Med Colomb 2017; 42: 112-120).