Episode 377: Creating and Implementing Radiopharmaceutical Policies and Procedures

“Policies help make sure that we’re giving patients the right education and discharge instructions. Radiation doesn’t end when the syringe is empty. Patients go home with potential radioactive exposure. They need to know how to protect their families, what precautions to take, and what healthcare providers can do if something goes wrong—like a spill, extravasation, or even a pregnant staff member who’s involved in the care. This isn’t just a documentation exercise. It’s about making sure every part of the system speaks the same language when it comes to safety, handling, and patient care,” ONS member Ella-Mae Shupe, MSN, RN, OCN^®, nursing practice and professional development specialist for radiation oncology at Johns Hopkins Health System Sydney Kimmel Cancer Center based in Baltimore, MD, told Jaime Weimer, MSN, RN, AGCNS-BS, AOCNS^®, manager of oncology nursing practice at ONS, during a conversation about creating and implementing radiopharmaceutical policies and procedures. 

Music Credit: “Fireflies and Stardust” by Kevin MacLeod 

Licensed under Creative Commons by Attribution 3.0  

Earn 0.5 contact hours of nursing continuing professional development (NCPD) by listening to the full recording and completing an evaluation at courses.ons.org by August 22, 2026. The planners and faculty for this episode have no relevant financial relationships with ineligible companies to disclose. ONS is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center’s Commission on Accreditation. 

Learning outcome: Learner will report an increase in knowledge related to implementing policies and procedures to support administration of radiopharmaceuticals for cancer treatment.

Episode Notes  

• Complete this evaluation for free NCPD.
• ONS Podcast™ episodes:
  • Episode 347: Care Considerations for Radiopharmaceuticals and Theranostics in Patients With Cancer
  • Episode 301: Radiation Oncology: Side Effect and Care Coordination Best Practices
  • Episode 298: Radiation Oncology: Nursing’s Essential Roles
  • Episode 104: How Radiation Affects All Areas of Oncology Nursing
• ONS Voice articles:
  • New Radiopharmaceutical Improves Survival in Advanced Prostate Cancer
  • Radiopharmaceuticals and Theranostics Offer New Options for Oncology Nurses to Transform Cancer Care
  • Radiopharmaceuticals Pack a One-Two Punch Against Cancer
  • Safety Is Key in Use of Radiopharmaceuticals
• ONS Voice oncology drug reference sheets:
  • Lutetium Lu 177 Dotatate
  • Lutetium Lu 177 Vipivotide Tetraxetan
  • Radium 223 Dichloride
  • Sodium Iodide-131
• ONS book: Manual for Radiation Oncology Nursing Practice and Education (Fifth Edition)
• ONS course: ONS/ONCC^® Radiation Therapy Certificate™
• Clinical Journal of Oncology Nursing article: Nursing Telemedicine Educational Encounters: Improved Patient Satisfaction in Radiation Therapy Clinics
• Other ONS resources:
  • ONS Radiation Learning Library
  • ONS Radiation Safety: In the Home Huddle Card
  • ONS Radiopharmaceuticals Huddle Card
• Daily Med
• Lutathera^® website for healthcare professionals
• Pluvicto^® website for healthcare professionals
• Xofigo^® website for healthcare professionals

To discuss the information in this episode with other oncology nurses, visit the ONS Communities.  

To find resources for creating an ONS Podcast club in your chapter or nursing community, visit the ONS Podcast Library. 

To provide feedback or otherwise reach ONS about the podcast, email [email protected].

Highlights From This Episode 

“[Lutetium lu 177 vipivotide tetraxetan] has shown so effective in clinical studies that the FDA recently approved expanded use, and it can now be given prior to chemotherapy.” TS 1:56

“There are typically three parts to a radiopharmaceutical. One is a radioisotope, which emits the radiation. The second is a targeting molecule, which directs the compound to a specific site. And the third is a linker that binds the isotope to the targeting molecules securely. The targeting molecule is usually a substance that binds specifically to receptors, antigens, or metabolic pathways that are overexpressed on cancer cells.” TS 2:08 

“We have an interdisciplinary team involvement. There’s a physicist, nurse, and provider that confirm lab values are within normal limits. The patient meets all the clinical and safety criteria for administration. Second is an IV placement where a nurse or clin tech starts the IV and verifies a strong blood return. This is critical to avoid extravasation, which can be harmful due to the vesicant-like nature of radiopharmaceuticals. And third, our patient voids immediately before the injection, which reduces bladder radiation dose. During the administration, our provider administers the radiopharmaceutical using a shielded syringe holder to reduce radiation exposure. The physicist remains present throughout the procedure. Lead aprons are worn by any team members close to the IV site, and then the Geiger counter is used by physics to measure ionizing radiation, which is done before, during, and after the procedure.” TS 3:28

“The policy we created doesn’t just address general principles. It includes very specific guidance for both [radium 223 dichloride] and [lutetium lu 177 vipivotide tetraxetan]. That includes everything from determining patient eligibility to completing the treatment directive, confirming patient identity, verifying delivery parameters, documenting the treatment itself, and ensuring the treatment environment is appropriate and safe. We’ve also built in drug- specific practices because [radium 223 dichloride] and [lutetium lu 177 vipivotide tetraxetan] each come with their own considerations. This includes competencies for nursing, tailored patient education for each therapy, and an extravasation checklist that outlines what to do and who’s responsible for tasks if infiltration occurs.”TS 11:24

“We created two separate versions [of an attestation model], one for clinical staff and one for non-clinical staff. Why include non-clinical staff? Because the risks extend beyond just the clinical team. What if environmental services comes in to clean and the patient has urinated on the floor? Or what if dietary delivers a tray and moves a urinal without knowing the risk? Or what if transport comes in and handles an incontinent brief without awareness? Each of these scenarios has potential for contamination and exposure. And that’s exactly why education for all roles matter.” TS 15:22

“These are such an exciting treatment for our patients, that’s not chemotherapy, that’s not radiation, and their quality of life has been amazing. We have had patients coming in that could barely walk because of the pain from bone mets and after a few treatments, they’re much better. We’ve had PSAs go from five, six hundreds down to 0.5, so we’re seeing a lot of really good options for these patients and treatment.” TS 22:09