SACT Competency Database - LTHT Medical, Nursing & Pharmacy

Publication: 01/03/2015  
Next review: 21/09/2025  
Standard Operating Procedure
ID: 4464 
Approved By:  
Copyright© Leeds Teaching Hospitals NHS Trust 2022  


This Standard Operating Procedure is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

LTHT Medical, Nursing & Pharmacy SACT Competency Database

This SOP should be followed by all Registrar and Consultant level staff, Registered Nurses and Pharmacists, who are authorized to prescribe, verify and administer systemic anti-cancer SACT for adult patients.

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To standardise the recording of SACT competency based training on a database which can be accessed on the hospital intranet for medical, pharmacy and nursing disciplines.
Chemotherapy - Leeds Teaching Hospitals NHS Trust (

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Background and indications for standard operating procedure

This SOP should be followed to ensure patient safety in the prescribing, checking and delivery of SACT for adult patients. The NHS England Quality Surveillance Measures: Cancer SACT: Adult (2018) mandates that the Clinical SACT Service must be able to provide current training records in each specific area of competence.

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Procedure method (step by step)

The Leeds Cancer Centre is responsible for:

  • Management of the SACT competency registers.
  • Ensuring the SACT register is kept up to date.
  • Informing the lead SACT pharmacist, the senior SACT nurse, the SACT lead clinician and deputy as well as the CSU Matron and senior sisters in SACT areas of updated key documents.

The SACT database is split into three sections which include:

  • SACT prescribers register
  • SACT verification register
  • SACT administrators register

Only those staff members who have been trained and assessed as competent in a particular task and are named on the SACT register for a given task in the SACT process are permitted to perform that task within the trust.

The Leeds Cancer Centre will hold a list of medical, pharmacy and nursing staff with designated responsibility for authorising the entry of an eligible person onto that part of the register for that respective task. This list of competency assessors will be agreed by the SACT medical, pharmacy and nursing lead for the Leeds Cancer Centre.

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Assessor of competence for prescribers (medical), and non-medical prescribers:

Assessors of prescribing competencies must;

  • Be of consultant grade and work in Clinical Oncology, Medical Oncology or Haematology at LTHT.
  • Have been awarded a Certificate of Completion of Specialist Training (CCST) in Clinical Oncology, Medical Oncology or Haematology.
  • Have ideally completed a training module for Educational Supervisors or have evidence of equivalent training.

Inclusion on the database as an assessor is renewed bi-annually and requires confirmation that the assessor;

  • Has prescribed/supervised the prescription of SACT within the last 12 months
  • Has had an annual appraisal.
  • Is familiar with the current SACT Competency Levels and suggested assessments.
  • The above is confirmed by self-assessment and signed off by the SACT Lead Clinician.

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Assessors of competence for verification (pharmacist)

The criteria for acting as an assessor of competence are adopted locally at LTHT. Those responsible for assessment must meet the following criteria;

  • Spend at least 50% of their time practicing the competencies as defined in the LCC standard operating procedures for verification of SACT.
  • Undertake regular CPD.
  • Have no areas of concern with their own practice e.g. acceptable error rates.

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Assessor of competence for SACT administration (nursing)

Those responsible for assessment must meet the following criteria;

  • Hold a teaching & assessing qualification/practice assessor e.g. ENB 998, MIP, SLIP.
  • Must have given SACT for over 18 months.
  • Must have completed a UKONS Safe Handling & Administration Trust Assessor Certificate. This form must be signed by approved SACT assessor, band 7 or above.
  • Must be SACT competent themselves.
  • Assessors must be competent in the clinical skill which they are assessing e.g. if assessing a staff member in cannulation and giving bolus vesicant SACT then they must also be skilled and competent in this task.

Refer to the LTHT SACT Administration Guideline

The management of the SACT prescribers register will be coordinated by the Business Manager for the Leeds Cancer Centre
The Senior Chemotherapy Nurse is responsible for the SACT administration register.
The Lead SACT Pharmacist is responsible for the SACT verification register

These registers will be updated on the hospital intranet on an on-going basis by the above professions

  • Once the member of staff has been assessed as competent, the assessment form must be signed by the assessor.
  • The competency assessment sheet acts as the written confirmation that the member of staff has completed the training and is competent to be included on the register. This must include details of which part of the register the member of staff is authorized for, details of the member of staff and the date of signing.
  • This document is retained by the member of staff.

For consultant prescribers/assessors, Registrar, Trust doctors and Non -Medical Prescribers the forms can be accessed on the intranet

The prescribing competency SOP can be accessed for reference here

Once completed, a copy of this document is forwarded to a clerical person who is nominated by the Business Manager of the Leeds Cancer Centre by the assessor. Once received by the Cancer Centre, the individual and their relevant details will be entered onto the register. Staff have access to this register

For nurses administering SACT the competency forms can be accessed via
Adult Systemic Anti-Cancer Therapy (SACT) Competency Registers - Leeds Teaching Hospitals NHS Trust (
Once completed, a copy of this document is forwarded to the Senior Chemotherapy Nurse.

Pharmacists should complete local competency assessment, and forward to the Lead SACT pharmacist.

  • At their subsequent review of competence, or at any other time, the SACT medical, pharmacy or nursing lead or the competency assessors have the authority to delete a staff member from the register.
  • The Leeds Cancer Centre will keep expired copies of staff’s competency check lists for 2 years after the current year of registration.
  • Registered Nurses who administer SACT will be re-assessed on their ability to remain on the administration register on an annual basis.
  • Medical and Non-Medical Prescribers (Nurses, Pharmacists, ACP’s) will be re assessed on their ability to remain on the prescribers register on a biannual basis
  • Pharmacists, will be re assessed on their ability to remain on the verification register on a biannual basis. This will be identified at their appraisal.
  • For nursing and medical staff, two months prior to the date re-registration is required, an email reminder will be sent to the member of staff. The member of staff will be expected to complete an assessment of competence again with their assessor. If satisfactory, and the assessment of competence is complete - the register will be updated accordingly.
  • If no response is received a further reminder will be sent after 1 month.
    If the member of staff is considered to no longer be competent in this area, or if the
    documentation is not received, the person will be removed from the register.


Record: 4464
Clinical condition:
Target patient group:
Target professional group(s): Pharmacists
Secondary Care Doctors
Secondary Care Nurses
Adapted from:

Evidence base

NHS England Quality Surveillance Measures: Cancer SACT: Adult (2018)

LTHT Guidelines for the Checking, Administration & Handling of Systemic Anti-Cancer Treatment (SACT) (May 2019)

LTHT Standard Operating Procedure: Adult SACT/SACT Prescribing Competencies
(December 2021)

Document history

LHP version 3.0

Related information

Not supplied

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