Pediatric clinical practice guidelines (CPGs) on chemotherapy-induced vomiting (CIV) control were adapted for use at our institution. Palonosetron use was limited due to cost. The primary objective of this study was to determine the extent that palonosetron use was discordant with the institutional policy and CPG. We conducted a retrospective review of pediatric patients who received palonosetron when receiving chemotherapy at SickKids between July 1 st, 2019, and June 30 th, 2020. Most (72%) palonosetron doses were discordant with institutional policy; 27% were discordant with the CPG. Our institutional policy has since been updated and is now more aligned with the CPG.