Safety analysis of occupational exposure of healthcare workers to residual contaminations of cytotoxic drugs using FMECA security approach

Four-year follow-up of surface contamination by antineoplastic drugs in a compounding unit

OBJECTIVES

This study aimed to monitor the contamination by antineoplastic drugs on work surfaces in a compounding unit 4 years after its implementation.

METHODS

This descriptive study was done in a unit performing on average 45 000 preparations per year. Surface sampling points (N=23) were monitored monthly in the frame of routine activity from the opening of an anticancer drug compounding unit. Contamination with nine antineoplastic drugs (cyclophosphamide, ifosfamide, dacarbazine, 5-fluorouracil, methotrexate, gemcitabine, cytarabine, irinotecan and doxorubicin) was assessed on wipes with a local liquid chromatography coupled with a tandem mass spectrometer analysis. The contamination rate (CR, %) was prospectively monitored every month during the entire study period. The occurrence of critical incidents was also registered. The effect of each safety measure implemented during this period was also analysed.

RESULTS

Based on the 1104 samples collected between March 2016 and March 2020, the CR was 18.5%. If three different critical incidents among a vial breakage that occurred were individually considered, this CR was slightly lower than that in the literature. Eight months after opening and taking different corrective actions, the overall CR dropped from 42.39% to 11.52% (p<0.001). Contamination was limited to the area that includes the compounding room and, more precisely, the welder and the QC-Prep⁺ sampling points.

CONCLUSIONS

From the beginning of the study and from month to month, surface contamination was limited to the nearest sampling points to the compounding unit. This 4-year monitoring study allowed us to determine the intravenous conventional antineoplastic drugs and sampling points to be focused on.

New Risk Methodology Based on Control Charts to Assess Occupational Risks in Manufacturing Processes

The accident rate in the EU-28 region of the European Union showed a value of 2 fatal accidents per 100,000 people in 2019 that mainly affect construction (24%), manufacturing (19%) and logistics (19 %). To manage situations that affect occupational risk at work, a review of existing tools is first carried out taking into account three prevention, simultaneity and immediacy characteristics. As a result, a new dynamic methodology called Statistical Risk Control (SRC) based on Bayesian inference, control charts and analysis of the hidden Markov chain is presented. The objective is to detect a situation outside the limits early enough to allow corrective actions to reduce the risk before an accident occurs. A case is developed in a medium-density fiberboard (MDF) manufacturing plant, in which five inference models based on Poisson, exponential and Weibull distributions and risk parameters following gamma and normal distributions have been tested. The results show that the methodology offers all three characteristics, together with a better understanding of the evolution of the operators in the plant and the safety barriers in the scenario under study.

Measuring and Reducing Chemical Spills by Students: A Randomized Controlled Trial of Providing Feedback

The ability to handle chemicals safely is a key aspect of the learning development of students studying chemistry; however, there have been no previously reported investigations of the quantity of chemicals spilled by students during lab experiments. Therefore, the first part of this article reports the assessment of the volume of chemicals spilled by year 1 undergraduate chemistry students (n = 64) at a U.K. university during an existing chemical analysis practical designed to develop volumetric handling skills. The experiment was carried out on paper liners, allowing the areas of students' spills to be visible and quantified using calibrated spill volumes of liquid to determine the resultant spill area. The volume spilled by the student group was ca. 1.2% of that handled; however, the amount spilled by individual students ranged widely, from ca. 0.02% to ca. 10% of the volume handled. A feedback tool has been developed to allow laboratory demonstrators to rapidly quantify chemical spillage by individual students. This tool also provides the demonstrators with a framework to communicate the potential safety significance of the volume of chemical a student has spilled. A randomized controlled trial (RCT) was carried out to examine the effect of providing feedback to students on their chemical spillage during a subsequent experiment. From a cohort of 185 year 1 undergraduate students, 150 consented to be randomized (81%), and data was collected for 144 students (96% of those randomized). A Hodges-Lehmann estimator for the median change in volume spilled during the second experiment due to providing feedback on spillage during first experiment was a 50% decrease in volume spilled (95% confidence range: 0 to 80% decrease, Mann-Whitney U test p = 0.05). The RCT was a waiting list trial, with all student receiving feedback either during or after the RCT, with blinded assessment by the demonstrators assessing volume spilled for the RCT.

[Prospective risk analysis in a retrocession unit: Focus on drug dispensation process]

OBJECTIVES

Failure mode effect analysis (FMEA) improves safety in the drug life cycle. As the drug dispensation by hospital's pharmacy can be at risk, the FMEA tool has been used to evaluate and enhance the process.

METHODS

After detailing the process, a first FMEA has been run in 2015. Corrective actions were implemented every time criticality indexes (CI) were above 15. One year later, we have evaluated potential impacts of these actions by running a new FMEA.

RESULTS

In 2015, 11 failure modes were prioritized (CI>15) and the total CI for the overall process was 397. Corrective actions were implemented and one year later this amount has decreased by 14% (340) with 6 failure modes still prioritized. Thus, thanks to the FMEA, risks could be identified in year "y", they were taken into account and corrected and then effectively reassessed in year "y+1".

CONCLUSION

This study showed us the interest of performing FMEA analysis in the drug dispensation process by hospital. The renewal of this risk analysis after a year helped us to monitor corrective actions, to evaluate their effectiveness and to improve safety. Finally, FMEA seems to be an effective way to steer the drug dispensation process.

Cross-Sectional Evaluation of Surface Contamination with Antineoplastic Drugs in Canadian Health Care Centres

BACKGROUND

Surfaces in health care centres are often contaminated with traces of antineoplastic drugs. Such contamination should be limited as much as possible, to reduce workers' exposure.

OBJECTIVES

The primary objective was to monitor environmental contamination with 9 antineoplastic drugs in oncology pharmacy and patient care areas of Canadian health care centres. The secondary objective was to explore the use of sodium hypochlorite as a cleaning agent for cyclophosphamide contamination.

METHODS

This cross-sectional evaluation was conducted from January to April 2018. Twelve standardized sites were sampled at each participating centre: 6 in the oncology pharmacy and 6 in patient care areas. Six of the antineoplastic drugs (cyclophosphamide, ifosfamide, methotrexate, gemcitabine, 5-fluorouracil, and irinotecan) were quantified by ultra-performance liquid chromatography - tandem mass spectrometry. For the other 3 antineoplastic drugs (docetaxel, paclitaxel, and vinorelbine), samples were screened for contamination but not quantified. The effect of using sodium hypochlorite as a cleaning agent was evaluated with a Kolmogorov-Smirnov test for independent samples.

RESULTS

Of 202 Canadian centres invited, 79 participated. A total of 887 surface samples were analyzed, 467 from pharmacy areas and 420 from patient care areas. Cyclophosphamide was the drug most often found as a contaminant (32.2% [286/887] of samples positive, 75th percentile of measured contamination 0.0017 ng/cm², 90th percentile 0.021 ng/cm²). The front grille inside the hood (80.8% [63/78] of samples positive for at least one antineoplastic drug), treatment chair armrest (78.9% [60/76]), storage shelf in pharmacy (61.5% [48/78]), and floor in front of the hood (60.3% [47/78]) were the most frequently contaminated surfaces. Cleaning with a sodium hypochlorite solution was highly variable. Among centres that reported using sodium hypochlorite to clean armrests on patient chairs, the concentration of cyclophosphamide was lower (0.00866 versus 0.0300 ng/cm², p = 0.014).

CONCLUSIONS

Despite growing awareness and implementation of new safe-handling guidelines, surfaces in health care centres were contaminated with traces of many antineoplastic drugs. Providing centres with attainable goals (e.g., 75th to 90th percentile relative to other similar centres) would help in identifying the sampling sites where improvements are needed and in achieving lower surface contamination.

Occupational risks evaluation in a centralized antineoplastic agent preparation unit

Objective:

The global professional risk assessment applied to the central unit of antineoplastic agent preparations is part of a mandatory approach required by the European legislation for workers. This study identified the hazardous situations related to the staff activity and then enabled the preparation of a formal plan of occupational prevention.

Methods:

The nature of study approved by a working group constituted by experts was the global risk analysis. After identifying the hazardous situations, the global risk analysis estimated the risk level of each hazardous situation based on a criticality score, including severity and frequency. The global risk analysis highlighted the initial and residual risks after establishing a plan to reduce the high criticality risks.

Results:

Hence, 33 unacceptable hazardous situations were identified. The critical categories of professional risks were “Product, emissions, and waste risks” with 17 (55%) hazardous situations; “Psychosocial risk factors” with 8 (24%) hazardous situations; and “Risks related to work equipment” with 6 (18%) hazardous situations. Once the risk reduction plan was in place, all hazardous situations were considered under control. The corrective actions led to a reorganization of human resources, the update of protection protocols, and optimization of ergonomic work tools. Staff-specific medical monitoring and regular surface contamination tests have been scheduled annually. In addition, initial and continuous training, specific to product and waste risks, has been updated.

Conclusion:

The global professional risk assessment related to centralized antineoplastic agent preparation unit generated failure in our system and enabled corrective actions for staff safety.

Pre and post intervention study of antiblastic drugs contamination surface levels at a Pharmacy Department Compounding Area using a closed system drug transfer device and a decontamination process

Assuring healthcare workers security on Hazardous Drugs (HD) compounding is critical in healthcare settings. Our study aims to demonstrate that the use of a Close System drug Transfer Device (CSTD) PhaSeal™ added to a decontamination process reduces antiblastic surface contamination levels in the Compounding Area (CA) of our Pharmacy Department (PD). We selected cyclophosphamide, 5-fluorouracil and iphosphamide to be evaluated. Testing was carried out with a wipe kit and quantified by an independent laboratory. We defined four sampling times: baseline; just after a decontamination procedure, which was repeated weekly during the study; four months after introduction of CSTD PhaSeal™ for cyclophosphamide and 5-fluorouracil compounding; and after eight months using CSTD PhaSeal™ for cyclophosphamide and 5-fluorouracil and one month for iphosphamide compounding. There was a decrease at the number of positive samples at the beginning/end of the study for all the drugs tested: 28/15 for cyclophosphide, 29/23 for iphosphamide and 7/1 for 5-fluorouracile. Comparing to the baseline, median cyclophosphamide levels significantly decreased (p-value <0.001) at 4 and 8 months sampling time (baseline: 1.01 ng/cm² to 0.06 ng/cm² and 0.01 ng/cm²), and median iphosphamide levels significantly decreased (p < 0.001) at 8 months sampling time (baseline: 3.02 ng/cm² to 0.06 ng/cm²). 5-Fluorouracil did not show significant differences between the sampling times (baseline: 0.09 ng/cm² to 0.09 ng/cm²). We saw a significant increase at iphosphamide levels at 4 months sampling point, contrary to cyclophosphamide, which levels had decreased. The use of CSTD PhaSeal™ for iphosphamide compounding the last month was implemented for ethical reasons after this intermediate results review. Our study suggests that the use of CSTD PhaSeal™, adding to decontaminating procedures, significantly reduces antiblastic drug surface levels at the CA of our PD.