Incidence and risk factors of preparation errors in a centralized cytotoxic preparation unit

A room of errors simulation to improve pharmacy operators' knowledge of cytotoxic drug production

INTRODUCTION

We used an educational healthcare simulation tool called room of errors (ROE) to raise pharmacy operators' awareness of potential errors in a chemotherapy production process and assessed its impact on their knowledge and satisfaction.

METHODS

Twenty-five errors (compiled from internal procedures, literature and our hospital's reported incidents) were categorised as static (n = 7, visible by the participant anytime) and dynamic (n = 18, made by a pseudooperator in front of the participant). Our simulated cytotoxic production unit (CPU) hosted the 1 h-simulation. Two pharmacists (supervisor/pseudo-operator) welcomed the trainee for a 10-min briefing. During the 20-min simulation, participants watched the pseudo-operator's gestures in a simulated chemotherapy production process. Participants called out each error observed (recorded by the supervisor). A 20-min debriefing followed. ROE's impact on knowledge was measured through participants' answers to a before-and after 18-item questionnaire about CPU's procedures and certainty about answers on a scale (0%-100%). Participants evaluated the training using a satisfaction questionnaire (Likert scale, 1-6).

RESULTS

The 14 participants detected 70.4% ± 11.4% of errors. Least-detected errors were "using non-disinfected vials" (42.9%) and "touching syringe plunger" (0%). Critical errors (expired leftovers or glucose instead of sodium chloride) were detected at 57.1%. Knowledge improved from 60.3% to 94.1% (p < 0.001) and certainty from 75.3% to 98.8% (p < 0.001). Participants appreciated this non-judgmental, informative, and original training (satisfaction 95.7%). Some pointed out difficulties settling into the game quickly and visualising static and dynamic errors simultaneously.

CONCLUSION

This ROE simulation improved operators' knowledge and certainty. Longer-term testing should be done to measure knowledge retention over time.

Computer programs used in the field of hospital pharmacy for the management of dangerous drugs: systematic review of literature

Background

This review wants to highlight the importance of computer programs used to control the steps in the management of dangerous drugs. It must be taken into account that there are phases in the process of handling dangerous medicines in pharmacy services that pose a risk to the healthcare personnel who handle them. Objective: To review the scientific literature to determine what computer programs have been used in the field of hospital pharmacy for the management of dangerous drugs (HDs).

Methods

The following electronic databases were searched from inception to July 30, 2021: MEDLINE (via PubMed), Embase, Cochrane Library, Scopus, Web of Science, Latin American and Caribbean Literature in Health Sciences (LILACS) and Medicine in Spanish (MEDES). The following terms were used in the search strategy: "Antineoplastic Agents," "Cytostatic Agents," "Hazardous Substances," "Medical Informatics Applications," "Mobile Applications," "Software," "Software Design," and "Pharmacy Service, Hospital."

Results

A total of 104 studies were retrieved form the databases, and 18 additional studies were obtained by manually searching the reference lists of the included studies and by consulting experts. Once the inclusion and exclusion criteria were applied, 26 studies were ultimately included in this review. Most of the applications described in the included studies were used for the management of antineoplastic drugs. The most commonly controlled stage was electronic prescription; 18 studies and 7 interventions carried out in the preparation stage focused on evaluating the accuracy of chemotherapy preparations.

Conclusion

Antineoplastic electronic prescription software was the most widely implemented software at the hospital level. No software was found to control the entire HD process. Only one of the selected studies measured safety events in workers who handle HDs. Moreover, health personnel were found to be satisfied with the implementation of this type of technology for daily work with these medications. All studies reviewed herein considered patient safety as their final objective. However, none of the studies evaluated the risk of HD exposure among workers.

Error Detection and Cost Savings With an Image-Based Workflow Management System Connected to a Computerized Prescription Order Entry Program for Antineoplastic Compounding

OBJECTIVE

The aim of the study was to analyze both the prevalence of errors with the implementation of an image-based workflow management system during the antineoplastic compounding process, and the estimated costs associated with the negative clinical outcome if the errors had not been intercepted.

METHODS

Three months after the implementation of Phocus Rx system at a hospital pharmacy department, the identification, classification (type, preparation stage, and cause), and potential severity degree (from negligible to catastrophic) of the errors intercepted were determined. The probability of an error causing an adverse event if it had reached the patient (from nil [0] to high [0.6]) and its consequences was estimated by a team of clinical pharmacists and physicians. Cost-effectiveness analysis from the hospital's perspective was performed.

RESULTS

Overall, 9872 antineoplastic medications were prepared using Phocus Rx. The total compounding error rate was 0.8% (n = 78, 56 [69.2%] were related to incorrect dose, 20 [28.2%] to incorrect drug preparation or conditioning technique, and 2 [2.6%] were wrong drugs). Approximately 70% of the detected errors were classified as undetectable via the previous verification practice, with 11.55% judged to be potentially severe (n = 9) and 51.3% moderate (n = 29). Likelihood of occurrence of an adverse event was medium (0.4) to high (0.6) for 37.2% of the errors. Estimated cost ratio and return on investment were €4.21 and 321%, respectively.

CONCLUSIONS

The implementation of Phocus Rx prevented antineoplastic preparation errors that would have reached the patient otherwise. In addition, acquisition of this technology was estimated to be cost-effective.

Cardiotoxicity of Antineoplastic Therapies and Applications of Induced Pluripotent Stem Cell-Derived Cardiomyocytes

The therapeutic landscape for the treatment of cancer has evolved significantly in recent decades, aided by the development of effective oncology drugs. However, many cancer drugs are often poorly tolerated by the body and in particular the cardiovascular system, causing adverse and sometimes fatal side effects that negate the chemotherapeutic benefits. The prevalence and severity of chemotherapy-induced cardiotoxicity warrants a deeper investigation of the mechanisms and implicating factors in this phenomenon, and a consolidation of scientific efforts to develop mitigating strategies. Aiding these efforts is the emergence of induced pluripotent stem cells (iPSCs) in recent years, which has allowed for the generation of iPSC-derived cardiomyocytes (iPSC-CMs): a human-based, patient-derived, and genetically variable platform that can be applied to the study of chemotherapy-induced cardiotoxicity and beyond. After surveying chemotherapy-induced cardiotoxicity and the associated chemotherapeutic agents, we discuss the use of iPSC-CMs in cardiotoxicity modeling, drug screening, and other potential applications. Improvements to the iPSC-CM platform, such as the development of more adult-like cardiomyocytes and ongoing advances in biotechnology, will only enhance the utility of iPSC-CMs in both basic science and clinical applications.

Prevalence and determinants of intravenous admixture preparation errors: A prospective observational study in a university hospital

Background Intravenous admixture preparation errors (IAPEs) may lead to patient harm. Insight into the prevalence as well as the determinants associated with these IAPEs is needed to elicit preventive measures. Aim The primary aim of this study was to assess the prevalence of IAPEs. Secondary aims were to identify the type, severity, and determinants of IAPEs. Method A prospective observational study was performed in a Dutch university hospital. IAPE data were collected by disguised observation. The primary outcome was the proportion of admixtures with one or more IAPEs. Descriptive statistics were used for the prevalence, type, and severity of IAPEs. Mixed-effects logistic regression analyses were used to estimate the determinants of IAPEs. Results A total of 533 IAPEs occurred in 367 of 614 admixtures (59.8%) prepared by nursing staff. The most prevalent errors were wrong preparation technique (n = 257) and wrong volume of infusion fluid (n = 107). Fifty-nine IAPEs (11.1%) were potentially harmful. The following variables were associated with IAPEs: multistep versus single-step preparations (adjusted odds ratio [OR_adj] 4.08, 95% confidence interval [CI] 2.27–7.35); interruption versus no interruption (OR_adj 2.32, CI 1.13–4.74); weekend versus weekdays (OR_adj 2.12, CI 1.14–3.95); time window 2 p.m.-6 p.m. versus 7 a.m.-10 a.m. (OR_adj 3.38, CI 1.60–7.15); and paediatric versus adult wards (OR_adj 0.14, CI 0.06–0.37). Conclusion IAPEs, including harmful IAPEs, occurred frequently. The determinants associated with IAPEs point to factors associated with preparation complexity and working conditions. Strategies to reduce the occurrence of IAPEs and therefore patient harm should target the identified determinants.

Healthcare failure mode and effect analysis in the chemotherapy preparation process

PURPOSE

To conduct a Health Care Failure Mode and Effects Analysis (HFMEA) of the chemotherapy preparation process to identify the steps with the potential to cause errors, and to develop further strategies to improve the process and thus minimize the risk of errors.

METHODS

An HFMEA was conducted to identify and reduce preparation errors during the chemotherapy preparation process. A multidisciplinary team mapped the preparation process, formally identified all the steps, and then conducted a brainstorming session to determine potential failure modes and their potential effects. A severity and probability score for each failure mode, a hazard score (HS) and a total HS were calculated. A hazard analysis was conducted for each HS equal to or more than 8. Finally, an action plan was identified for each failure mode. After the action plan was implemented, failure modes were revaluated and a new HS score was calculated as well as the percentage decrease in risk.

RESULTS

The team identified five main steps in the chemotherapy preparation process and nine potential failure modes. After implementing the control measures, all the HSs decreased. The total HS associated with the chemotherapy preparation process decreased from 54 to 26 (-52%). This reduction in the total HS was mainly achieved by updating the Standard Operating Procedures (SOPs) and implementing bar code and gravimetric control system.

CONCLUSION

The application of HFMEA to the chemotherapy preparation process in centralized chemotherapy units can be very useful in identifying actions aimed at reducing errors in the healthcare setting.

Risk reduction in a cancer chemotherapy production unit: Contribution of an automated drug dispensing system

OBJECTIVE

The purpose of our study was to evaluate the contribution of an automated drug dispensing system in securing cancer chemotherapy production process at the pharmacy of the National Institute of Oncology in Rabat.

METHODS

The failure modes and effects analysis method was applied to the chemotherapy production process in two phases: Phase 1, using an open shelf for storage then phase 2, using an automated drug dispensing system. The failure modes were defined and their criticality indexes was calculated on the basis of the likelihood of occurrence, the potential severity for the patients and/or the impact on the process and the detection probability. The criticality indexes of the two phases were prioritized and compared.

RESULTS

We identified 35 failure modes for phase 1 and 37 for phase 2. The sum of criticality indexes was 5957 and 4586, respectively, for phase 1 and phase 2, corresponding to a criticality reduction of -23%. The greatest improvements concerned that the needed drug is missing during the picking, storage of potential expired drugs, and double compounding.

CONCLUSION

Our study highlighted the contribution of automated drug dispensing system in risk minimization. The use of automated drug dispensing system is a part of security improvement in chemotherapy production unit.

Optimisation of the preparation of chemotherapy based on 5-fluorouracil by the use of peristaltic pumps

Objectives

Preparation of 5-FU elastomeric pumps is a time-consuming activity inducing musculoskeletal disorders (MSDs). Our unit has developed an automated filling system consisting of two peristaltic pumps (one for the diluent, one for the cytotoxic drug). The objective was to validate the accuracy of the assembly and evaluate the impact of automation on the compounding time, occurrence of MSDs and cost of preparation.

Methods

Accuracy was determined by calculating the total error on the volumes injected by the pumps. Measurements were made for 2 brands (AMF, Baxter), 3 different volumes; repeated 3 times at 3 times of the day. The time-saving study compared 24 measurements in manual filling and 24 in automated mode. Impact of automation on the occurrence of MSDs was evaluated by a self-assessment questionnaire. Finally, a comparison between the price of a manually prepared elastomeric pump and an automated prepared elastomeric pump was performed.

Results

Volumes administered by the pumps were accurate (total error < 2.5%). Preparation time was divided by 2. Occurrence of MSD decreased (8.7 manual filling vs. 23.5/28 automated filling). Overcost was moderate (14.7% for AMF; 10.3% for Baxter).

Conclusions

Using peristaltic pumps, 5FU preparation was optimized for moderate additional cost.

Stability of calcium levofolinate reconstituted in syringes and diluted in NaCl 0.9% and glucose 5% polyolefin/polyamide infusion bags

Purpose

Calcium levofolinate (CaLev) for intravenous administration is commercially available as a powder that must be reconstituted for injection or reconstituted and then diluted before administration. The lack of stability data on CaLev solutions renders necessary extemporaneous manual preparation, preventing the use of automated/semi-automated systems, with a consequent loss in terms of quality and safety.

Methods

The present work assessed the chemical–physical and microbiological stability of CaLev prepared in sodium chloride 0.9%, glucose 5% and water for injections and stored in polyolefin/polyamide bags and polypropylene syringes at 2–8°C protected from light. For this purpose, we developed and validated a new rapid High Performance Liquid Chromatography with Ultra Violet Diode-Array Detection (HPLC-UV-DAD) method.

Results

The samples tested were stable for 14 days, retaining >95% of their initial concentration and showing no change in colour, turbidity or pH. Microbiological tests performed on the samples were negative.

Conclusions

Our results confirmed the analytical stability of CaLev in NaCl 0.9%, glucose 5% and water for injection at concentrations used in clinical practice at our institute. This enables our centralized laboratory to organize the preparation of this drug in advance and the use of robots rather than manual preparation reduces the workload and the risk of preparation errors.

Proposal of a simple and rapid method for the chemotherapy preparations analytical control by spectrophotometry UV-Vis method

INTRODUCTION

The preparation of anticancer chemotherapy in a hospital must meet several objectives; the first main is the quality, which can be provided by setting up a surveillance system and a quality control of each preparations. The aim of this work is to present a simple, fast and accurate spectrophotometric method for the routine control of cytotoxic preparations.

MATERIALS AND METHODS

This is a study carried out in the cytotoxic preparation unit of the university center of Rabat-Sale children's hospital in Morocco. All samples of preparations were collected and analyzed daily on the site. After validation of the analytical method with respect to many parameters such as: linearity, accuracy and precision according to ICH Q2 guidelines, samples of cytotoxic preparations collected were assayed.

RESULTS

The results are satisfactory with good level of exactitude, and high precision.

CONCLUSION

Compared to other techniques, this method can be considered as a useful alternative in the routine quality control of preparations. It can quickly obtain qualitative and quantitative information with instrumentation and inexpensive reagents.

Improvement of Chemotherapy Solutions Production Procedure in a Hospital Central Chemotherapy Preparation Unit: A Systematic Risk Assessment to Prevent Avoidable Harm in Cancer Patients

OBJECTIVE

This study was designed to reevaluate and improve the quality and safety of the chemotherapy preparation in a Central Chemotherapy Preparation Unit of a Public Hospital.

METHODS

A failure modes, effects, and criticality analysis (FMECA) was conducted by a multidisciplinary team. All potential failure modes at each stage of the chemotherapy preparation were recorded, and the associated risks were scored for their severity, occurrence, and detectability with a risk priority number (RPN). Corrective actions were suggested, and new RPNs were estimated for the modified process.

RESULTS

Failure modes, effects, and criticality analysis and priority matrix construction, revealed that the partial compliance of Unit's premises with international standards (RPNstage: 307), the human errors throughout the compounding (RPNstage: 223)-labeling (RPNstage: 216)-prescribing (RPNstage: 198) steps, and the violation of working protocols by employees (RPNstage: 215), were the most important risks for which either urgent or immediate corrective actions had to be taken. Modifying the procedure through the proposed corrective actions is expected to lead to a significant (71.3%) risk containment, with a total RPNpreparation process reduction from 2102 to 604.

CONCLUSIONS

Failure modes, effects, and criticality analysis and priority matrix development identified and prioritized effectively the risks associated with chemotherapy preparation allowing for the improvement of health services to cancer patients.

Work overload is related to increased risk of error during chemotherapy preparation

PURPOSE

Chemotherapy preparation units face peaks in activity leading to high workloads and increased stress. The present study evaluated the impact of work overloads on the safety and accuracy of manual preparations.

METHOD

Simulating overwork, operators were asked to produce increasing numbers of syringes (8, 16, and 24), with markers (phenylephrine or lidocaine), within 1 h, in an isolator, under aseptic conditions. Results were analyzed using qualitative and quantitative criteria. Concentration deviations of < 5%, 5%-10%, 10%-30%, and >30% from the expected concentration were considered as accurate, weakly accurate, inaccurate, and wrong concentrations, respectively.

RESULTS

Twenty-one pharmacy technicians and pharmacists carried out 63 preparation sessions (n = 1007 syringes). A statistically significant decrease in the manufacturing time for one syringe was observed when workload increased (p < 0.0001). Thirty-nine preparation errors were recorded: 30 wrong concentrations (deviation > 30%), 6 mislabeling, 2 wrong diluents, and 1 wrong drug. There was no statistically significant difference in the mean concentration accuracy of final preparations across the three workloads. The overall error rate increased with the number of preparations made in 1 h: 1.8% for 8 preparations, 2.7% for 16 preparations, and 5.4% for 24 preparations (p < 0.05).

CONCLUSION

Although pharmacy technicians and pharmacists were able to increase production speeds with no effect on mean concentration accuracy under stressful conditions, there were greater probability errors being made. These results should encourage actions to spread workloads out over the day to avoid peaks in activity.

A virtual centralized cytotoxic preparation unit simulation to evaluate the pharmacy staff knowledge

BACKGROUND

The risk of medication errors related to drug preparation unit cannot be totally avoided because of human interference. The aim of this study is to investigate the background and knowledge of the pharmacy staff by replicating the cytotoxic preparation unit with potential errors.

METHODS

A 10-m² room was provided to duplicate the centralized chemotherapy unit with three areas reproducing virtually the equipment preparation bench, the isolator, and the dispensing bench. The 14 situations selected by experts were integrated to each corresponded area. For each participant, a form was given and answers were analyzed by two independent experts. Statistical processing data were performed using GraphPad Prism® software.

RESULTS

A total of 19 professionals participated in error simulation workshop over a one-month period. The overall rate of correct responses was 58 ± 19%. In five situations, correct responses rate was lower than 50%: wrong drug batch related to the preparation sheet (40%), inappropriate sterilizing conditions (15%), the time on the preparation sheet provides an expired expiry date for melphalan preparation (45%), a maximum drug dose exceeded (25%), the dispensing form not corresponds to the preparation sheet and final product label (30%). The rate of correct responses was 45 ± 25% for professionals not specifically dedicated to chemotherapy preparation. The overall satisfaction workshop rate was 8.7 ± 1.0 out of 10.

CONCLUSION

This study showed the importance of training programs to sensitize personal staff to the risks of chemotherapy preparation and prevent errors.

Intravenous Chemotherapy Compounding Errors in a Follow-Up Pan-Canadian Observational Study

Purpose:

Intravenous (IV) compounding safety has garnered recent attention as a result of high-profile incidents, awareness efforts from the safety community, and increasingly stringent practice standards. New research with more-sensitive error detection techniques continues to reinforce that error rates with manual IV compounding are unacceptably high. In 2014, our team published an observational study that described three types of previously unrecognized and potentially catastrophic latent chemotherapy preparation errors in Canadian oncology pharmacies that would otherwise be undetectable. We expand on this research and explore whether additional potential human failures are yet to be addressed by practice standards.

Methods:

Field observations were conducted in four cancer center pharmacies in four Canadian provinces from January 2013 to February 2015. Human factors specialists observed and interviewed pharmacy managers, oncology pharmacists, pharmacy technicians, and pharmacy assistants as they carried out their work. Emphasis was on latent errors (potential human failures) that could lead to outcomes such as wrong drug, dose, or diluent.

Results:

Given the relatively short observational period, no active failures or actual errors were observed. However, 11 latent errors in chemotherapy compounding were identified. In terms of severity, all 11 errors create the potential for a patient to receive the wrong drug or dose, which in the context of cancer care, could lead to death or permanent loss of function. Three of the 11 practices were observed in our previous study, but eight were new. Applicable Canadian and international standards and guidelines do not explicitly address many of the potentially error-prone practices observed.

Conclusion:

We observed a significant degree of risk for error in manual mixing practice. These latent errors may exist in other regions where manual compounding of IV chemotherapy takes place. Continued efforts to advance standards, guidelines, technological innovation, and chemical quality testing are needed.

Analytical Control of Pediatric Chemotherapy Preparations with a UV-Raman Automaton: Results After 18 Months of Implementation and Development of A Suitable Method for Low Volume Preparations

Background

In France, control of chemotherapy preparations is highly recommended. Analytical control is a method of choice for identifying and quantifying drugs. Pediatric preparations, which often contain small quantities of drugs and are made in low final volumes were until then not analytically controlled. After the development and validation of a new sampling and assaying method for low volume chemotherapy preparations with an UV/Raman automaton (QCPrep +), the quality control results of the preparations intended for the patients were analyzed over a period of eighteen months

Methods

The results were studied by type of preparation (low and high volume), per molecule, manipulator, and conformity rates dispersion.

Results

Over the period, 7,548 controls were carried out, representing 87.7% of our production. 75.5% of these controls concerned low-volume preparations (<50mL). The overall conformity rate was 94.4%. The lowest conformity rates were found for vinca alkaloids, methotrexate and some rarely manipulated drugs (cisplatin, decitabine, epirubicin). The study of the results dispersion showed non-conformities increasing with low concentrations, specific to pediatrics. These results show the limits of analytical control for pediatric preparations. The low analytical sensitivity encountered for certain concentrations and drugs requires a complementary quality control tool, like camera or video. However this new analytical method allows us to improve the safety of the injectable chemotherapy circuit.

Conclusion

Young patients can benefit from the same level of safety and quality as adult patients. Some critical points could be highlighted: the homogenization of the preparations, the analytical sensitivity of some drugs and human factors. This data allow us to focus our work on staff training, improving our calibration ranges and on the development of complementary control tools.

Risk factors for i.v. compounding errors when using an automated workflow management system

PURPOSE

Results of a study to determine the frequency of and risk factors for errors in automated compounding of i.v. medication doses at a pediatric hospital are presented.

METHODS

Data compiled by the hospital's automated i.v. compounding workflow management system over a 12-month period were analyzed. A descriptive analysis was conducted to characterize intercepted errors by frequency and type. Multivariate regression analysis via a backward stepwise procedure was performed to identify notable risk factors for i.v. compounding errors.

RESULTS

Among the 421,730 i.v. doses evaluated, there were 3,101 documented errors (an overall error rate of 0.74%). The automated system intercepted 72.27% of the errors, mainly those containing an incorrect drug or diluent. The remaining 27.73% of i.v. compounding errors, primarily dose preparation in the wrong volume (21.51%) or damage to the final product (0.93%), were identified during final inspection by a pharmacist. The logistic regression model showed that four factors were significantly (p < 0.05) associated with an increased risk of compounding errors: dose preparation during the morning shift (relative risk [RR], 1.84; 95% CI, 1.68-2.02) or on a Sunday (RR, 1.28; 95% CI, 1.11-1.47), preparation of doses for use in critical care units (RR, 1.17; 95% CI, 1.07-1.28), and technician versus pharmacist compounding (RR, 1.17; 95% CI, 1.04-1.32).

CONCLUSION

Analysis of error reports generated by an i.v. compounding workflow management system at a large pediatric hospital over one year found an overall rate of detected errors of 0.74%. Four factors were identified as significant predictors of increased error risk.

Reliability of chemotherapy preparation processes: Evaluating independent double-checking and computer-assisted gravimetric control

Background and objectives Centralized chemotherapy preparation units have established systematic strategies to avoid errors. Our work aimed to evaluate the accuracy of manual preparations associated with different control methods. Method A simulation study in an operational setting used phenylephrine and lidocaine as markers. Each operator prepared syringes that were controlled using a different method during each of three sessions (no control, visual double-checking, and gravimetric control). Eight reconstitutions and dilutions were prepared in each session, with variable doses and volumes, using different concentrations of stock solutions. Results were analyzed according to qualitative (choice of stock solution) and quantitative criteria (accurate, <5% deviation from the target concentration; weakly accurate, 5%-10%; inaccurate, 10%-30%; wrong, >30% deviation). Results Eleven operators carried out 19 sessions. No final preparation (n = 438) contained a wrong drug. The protocol involving no control failed to detect 1 of 3 dose errors made and double-checking failed to detect 3 of 7 dose errors. The gravimetric control method detected all 5 out of 5 dose errors. The accuracy of the doses measured was equivalent across the control methods ( p = 0.63 Kruskal-Wallis). The final preparations ranged from 58% to 60% accurate, 25% to 27% weakly accurate, 14% to 17% inaccurate and 0.9% wrong. A high variability was observed between operators. Discussion Gravimetric control was the only method able to detect all dose errors, but it did not improve dose accuracy. A dose accuracy with <5% deviation cannot always be guaranteed using manual production. Automation should be considered in the future.

DrugCam®-An intelligent video camera system to make safe cytotoxic drug preparations

DrugCam(®) is a new approach to control the chemotherapy preparations with an intelligent video system that enables automatic verification during the critical stages of preparations combined with an a posteriori control with partial or total visualization of the video recording of preparations. The assessment was about the recognizing of anticancer drug vials (qualitative analysis) and syringe volumes (quantitative analysis). The qualitative analysis was conducted for a total of 120 vials with sensitivity of 100% for 84.2% of the vials and at least 97% for all the vials tested. Accuracy was at least 98.5% for all vials. The quantitative analysis was assessed by detecting 10 measures of each graduation for syringes. The identification error rate was 2.1% (244/11,640) i.e. almost 94% to the next graduation. Only 3% (35/1164) of the graduations tested, i.e. 23/35 for volume <0.13 ml of 1 ml syringes, presented a volume error outside the admissible limit of ± 5% of a confidence band constructed for the estimated linear regression line for each syringe. In addition to the vial detection model, barcodes can also read when they are present on vials. DrugCam(®) offers an innovative approach for controlling chemotherapy preparations and constitutes an optimized application of telepharmacy.

Implementation of Analytical Control of Low Volume Pediatric Cytotoxic Drugs Preparations using a UV/Raman Spectrophotometer

: Pediatric chemotherapy preparations are usually not analytically controlled, for several reasons. First, they are generally made in syringe, which does not allow to take a sample without changing the final volume. Secondly, the percentage of the dose consecrated to control is important and finally low concentrations can cause sensitivity problems. This lack of quality control, greatly reduces the security of the chemotherapy circuit.

: The main objective is to develop an analytical control to low volume pediatric preparations, made in syringes or in infusion bags with a final volume from 20 to 50 mL.

: The development of analytical control automatons, like QCPrep+

: Our protocol implies the overfilling with one milliliter of solvent followed by a sampling of one milliliter. The analysis is performed with 900 µL. Ten cytotoxic drugs commonly used in pediatric oncology have been validated according to ICH recommendations. The development of analytical control for low volume preparations allows young patients to benefit the same level of safety and quality than adult patients.

Economic assessment of aseptic compounding rooms in hospital pharmacies in five European countries

PURPOSE

The aims of the study are to make an inventory of fixtures of aseptic compounding structures, to compare, using real examples, the design and operating costs of controlled atmosphere area (CAA) with isolators and CAA with laminar flow biological safety cabinets (BSCs) in order to determine the most economical scheme in hospitals and to give a final facilities cost calculated for one workstation.

METHODS

Forty-three hospitals were interviewed (21 French and 22 from four European countries) over seven months. Hospital pharmacists completed a form with 390 items. Hospitals are compared according to their workstation type: BSCII or BSCIII (group B) and isolator (group I), using Mann and Whitney's statistical test and Monte-Carlo modeling.

RESULTS

Twenty-one hospitals responded (11 French and 10 from other European countries). All European compounding unit organizations are not significantly different. The study compared items such as infrastructure cost, equipment cost, staff cost, consumable cost, cleaning cost and control cost. A synthesis of all costs has been drafted to calculate an estimated preparation cost which seemed to be higher for group B than for group I when staff costs were included ($46 and $31, respectively, in study conditions).

CONCLUSIONS

The different costs studied have revealed little significant difference between group B and I. The preparation cost in group B appears higher than in group I. This pilot study has resulted in the calculation of an estimated manufactured preparation cost but this work should be completed to help optimize resources and save money.

Intravenous chemotherapy preparation errors: patient safety risks identified in a pan-Canadian exploratory study

BACKGROUND

This exploratory study was launched following a critical chemotherapy medication incident to thoroughly and proactively examine the current processes for ordering, preparing, labeling, verifying, administering, and documenting ambulatory intravenous chemotherapy in Canada, and to identify factors that may contribute to preventable adverse drug events.

METHODS

Field observations in six Canadian cancer centers to identify end-to-end processes in clinic, pharmacy, and treatment areas; analysis of processes to identify risks.

RESULTS

Three types of previously locally unrecognized potential chemotherapy preparation errors in Canadian oncology pharmacies were uncovered, all of which are undetectable if they occur. Although the frequency of these errors is unknown, their impact is potentially catastrophic.

INTERPRETATION

Dispensing errors in high-risk intravenous preparation have been studied in the past, but it is unlikely that these studies have detected these errors because of the inherent limitations of the detection methods used. Research on preparation errors using more sensitive methods is therefore urgently needed to establish the extent to which pharmacy preparation practices may be error-prone, and to allow reliable evaluation of the impact of mitigation strategies. Widespread practice changes in Canadian oncology pharmacies are necessary, and are currently underway.

Evaluation of safe infusion devices for antineoplastic administration

Nurses endure daily low-level exposure to cytotoxic drugs, which can lead to significant absorption with potential harmful consequences. New sterile medical devices called cytotoxic safe infusion systems (CSISs), intended by their manufacturers to improve safety and quality of cytotoxic drug infusions, have been made commercially available. CSISs from 3 manufacturers were tested in 2 cancer units and compared with standard infusion sets. The aim of this study is to evaluate the devices regarding occupational exposure, quality of the infusion, and economic aspects.

Chemotherapeutic errors in hospitalised cancer patients: attributable damage and extra costs

Background

In spite of increasing efforts to enhance patient safety, medication errors in hospitalised patients are still relatively common, but with potentially severe consequences. This study aimed to assess antineoplastic medication errors in both affected patients and intercepted cases in terms of frequency, severity for patients, and costs.

Methods

A 1-year prospective study was conducted in order to identify the medication errors that occurred during chemotherapy treatment of cancer patients at a French university hospital. The severity and potential consequences of intercepted errors were independently assessed by two physicians. A cost analysis was performed using a simulation of potential hospital stays, with estimations based on the costs of diagnosis-related groups.

Results

Among the 6, 607 antineoplastic prescriptions, 341 (5.2%) contained at least one error, corresponding to a total of 449 medication errors. However, most errors (n = 436) were intercepted before medication was administered to the patients. Prescription errors represented 91% of errors, followed by pharmaceutical (8%) and administration errors (1%). According to an independent estimation, 13.4% of avoided errors would have resulted in temporary injury and 2.6% in permanent damage, while 2.6% would have compromised the vital prognosis of the patient, with four to eight deaths thus being avoided. Overall, 13 medication errors reached the patient without causing damage, although two patients required enhanced monitoring. If the intercepted errors had not been discovered, they would have resulted in 216 additional days of hospitalisation and cost an estimated annual total of 92, 907€, comprising 69, 248€ (74%) in hospital stays and 23, 658€ (26%) in additional drugs.

Conclusion

Our findings point to the very small number of chemotherapy errors that actually reach patients, although problems in the chemotherapy ordering process are frequent, with the potential for being dangerous and costly.

Safety in the preparation of cytotoxic drugs: How to integrate gravimetric control in the quality assurance policy?

PURPOSE

We present the way to integrate gravimetric control (GC) in a centralized preparation of cytotoxic drugs unit. Two different modalities are described. In the first strategy, the balance is located inside the isolator, whereas in the second, it is located outside in order to remove many technical and ergonomic constraints. These two modalities are compared in terms of benefits and limits.

METHODS

GC consists in comparing the observed weight variation with the expected weight variation using a precision balance. According to the B-in strategy, this variation is directly attributable to the weight of the cytotoxic solution injected, whereas with the B-out strategy, the weight of various additional components must be taken into account.

RESULTS

Five hundred and seventy-seven preparations have been weighed. For "B-in" strategy, the 95% confidence interval is [1.02-1.14%] and every preparation is below the threshold of 5%. For "B-out" strategy, the 95% confidence interval is [2.34-2.63%] and 94% of preparations are below the threshold of 5%. B-in strategy is distinctly more precise than B-out strategy and can be applied to all preparations. However, B-out strategy is a feasible option in practice and enables the detection of an important mistake. All in all, results obtained from B-out strategy can be considered as a quality indicator in the production line.

CONCLUSION

Results of GC are helpful in the final step of release, which the pharmacist is responsible for. Many contributions in the quality assurance policy could justify using of GC in every unit.

Evaluation of clinical interventions made by pharmacists in chemotherapy preparation

Background

Cancer drugs are high risk drugs and medication errors in their prescribing, preparation and administration have serious consequences, including death. The importance of a multidisciplinary approach and the benefits of pharmacists’ contribution to cancer treatment to minimise risk have been established. However, the impact of services provided by pharmacists to cancer patient care is poorly studied. This study explored the clinical interventions made by pharmacists in dispensing of chemotherapy doses, and evaluated pharmacists’ contribution to patient care.

Methods

Pharmacists at the Chemotherapy Preparation Unit at a tertiary cancer centre in London were shadowed by two research pharmacists during the clinical screening of chemotherapy prescriptions and release of prepared drugs. An expert panel of pharmacy staff rated the clinical significance of the recorded interventions.

Results

Twenty-one pharmacists’ interventions were recorded during the screening or releasing of 130 prescriptions or drugs. “Drug and therapy” (38%), “clerical” (22%) and “dose, frequency and duration” (19%) related problems most often required an intervention, identifying areas in chemotherapy prescribing that need improvement. The proposed recommendations were implemented in 86% of the cases. Many recorded interventions (48%) were ranked to have had a “very significant” influence on patient care.

Conclusion

Clinical interventions made by pharmacists had a significant impact on patient care. The integration of pharmacists’ technical and clinical roles into dispensing of chemotherapy doses is required for providing high-quality cancer services.

Cisplatin preparation error; patient management and morbidity

INTRODUCTION

Antineoplastic drug therapy errors represent a high iatrogenic potential due to antineoplastic drugs narrow therapeutic ranges and the complexity of chemotherapy regimens that may increase the risk of morbidity and mortality for oncology patients.

SETTING

We report a 57-year-old man with head and neck cancer who mistakenly received 180 mg/ m(2) of cisplatin overdose despite the safety measures and validations carried out during preparation. The patient developed moderate nausea and vomiting, acute renal failure, hearing difficulty (tinnitus), and severe myelodepression. PATIENT MANAGEMENT: Prophylactic and symptomatic treatments were applied in order to prevent and correct toxicity during the 9 days stay at hospital.

RESULT

He recovered with mild tinnitus and mild renal impairment as the only sequelae. This case presents a hospital stay and treatment quite different to others used to reverse all cisplatin overdose toxicity and it shows the benefits of prompt management.

Telepharmacy and bar-code technology in an i.v. chemotherapy admixture area

PURPOSE

A program using telepharmacy and bar-code technology to increase the presence of the pharmacist at a critical risk point during chemotherapy preparation is described.

SUMMARY

Telepharmacy hardware and software were acquired, and an inspection camera was placed in a biological safety cabinet to allow the pharmacy technician to take digital photographs at various stages of the chemotherapy preparation process. Once the pharmacist checks the medication vials' agreement with the work label, the technician takes the product into the biological safety cabinet, where the appropriate patient is selected from the pending work list, a queue of patient orders sent from the pharmacy information system. The technician then scans the bar code on the vial. Assuming the bar code matches, the technician photographs the work label, vials, diluents and fluids to be used, and the syringe (before injecting the contents into the bag) along with the vial. The pharmacist views all images as a part of the final product-checking process. This process allows the pharmacist to verify that the correct quantity of medication was transferred from the primary source to a secondary container without being physically present at the time of transfer.

CONCLUSION

Telepharmacy and bar coding provide a means to improve the accuracy of chemotherapy preparation by decreasing the likelihood of using the incorrect product or quantity of drug. The system facilitates the reading of small product labels and removes the need for a pharmacist to handle contaminated syringes and vials when checking the final product.

Multidisciplinary system for detecting medication errors in antineoplastic chemotherapy

Objective. To analyze medication errors (MEs) in a multidisciplinary system with a Computerized Pharmacotherapy Process (CPP) in cancer patients.

Design. A longitudinal, prospective 2-year (January 2003 —to December 2004) cohort study was made in adult patients administered antineoplastic treatment in Services of Oncology and Haematology. MEs were identified by double cross-validation of each stage of the pharmacotherapeutic process (prescription, preparation, dispensing, administration, and follow-up) carried out by the multidisciplinary team (physician, pharmacist, nurse) with CPP assistance.

Variables. Number of MEs per 1000 patient-days, percentage according to the stage of the pharmacotherapeutic process and the severity of intercepted ME (scored from 1 = no damage to the patient, to 5 = patient death).

Results. A total of 1311 patients were receiving treatment, and MEs were identified in 225. Out of a total of 13,158 patient-days, 276 MEs were detected, equivalent to 20.9 MEs per 1000 patient-days; of these, 16.8 MEs per 1000 patient-days (80%) were intercepted and did not affect any patient. The detected ME distribution according to pharmacotherapeutic stage was: prescription 75.7%, preparation 21.0%, dispensing 1.8%, administration 1.1%, and follow-up 0.4%. ME distribution according to severity was: grade 1 : 15.9%, grade 2 : 49.6%, grade 3 : 33.7%, grade 4 : 0.7%, and grade 5 : 0%.

The system intercepted 98.9% of all MEs with severity ≥3 (MEs with a potential for causing patient damage).

Conclusions. The multidisciplinary system with a well-established CPP detects 20.9 MEs per 1000 patient-days and intercepts 98.8% of all MEs with a potential for causing patient damage. J Oncol Pharm Practice (2010) 16: 105—112.

Minimising treatment-associated risks in systemic cancer therapy

Aim of the review To review the consequences of drug-related problems (DRP) in systemic cancer therapy and identify specific contributions of the pharmacist to minimise treatment-associated risks. Method Searches in PubMed, Embase and the Cochrane Library were conducted. Bibliographies of retrieved articles were examined for additional references. Only papers in English between 1980 and 2007 were included. Results In systemic cancer therapy there is an enormous potential for DRP due to the high toxicity and the complexity of most therapeutic regimens. The most frequently reported DRP can be classified into adverse effects, drug–drug interactions, medication errors, and non-adherence. Pharmacists have enhanced efforts to assure quality and safety in systemic cancer therapy together with other health care providers. In consequence, oncology pharmacy has evolved as a novel specialist discipline. The endeavour to merge and co-ordinate individual activities and services of the pharmacist has led to pharmaceutical care concepts which aim at offering novel solutions to the various DRP. Conclusion Pharmaceutical care for cancer patients should be developed within research projects and integrated into disease management programs in order to ensure broad implementation.

Pharmaceutical validation as a process of improving the quality of antineoplastic treatment

OBJECTIVE

To quantify the improvement added by standardization of pharmaceutical validation (PV) of antineoplastic treatment to the processes of prescription and preparation of the pharmacotherapeutic sequence, in terms of prevention and reduction of medication errors (ME).

DESIGN

Prospective cohort study during two years (from 2001-2002) for oncohaematologic patients (inpatients and outpatients) that compared the percentage of medication errors detected and resolved and the number of medication errors with potential clinical significance (severity value >or=4) intercepted during PV in both years.

RESULTS

During the PV processes, 202 ME were identified and resolved, which is the equivalent of 16.88 ME/1,000 patient-days. In 2001 14.08 ME/1,000 patient-days were detected and 19.83 ME/1,000 patient-days in 2002. This means that the effectiveness of the identification method increased by 41%. The number of ME intercepted with clinical significance (severity value >or=4) increased in a statistically significant manner by 2.18 times in 2002.

CONCLUSION

This study shows that the standardization of PV is an effective method of improving the quality of antineoplastic treatment use, by increasing the ability to intercept ME.

Use of a prospective risk analysis method to improve the safety of the cancer chemotherapy process

OBJECTIVE

To perform a risk analysis of the cancer chemotherapy process, by comparing five different organizations. To quantitatively demonstrate the usefulness of centralization and information technologies, to identify residual risks that may be the target of additional actions.

STUDY DESIGN

A reengineering of the process started in 1999 and was planned to be finished in 2006. The analysis was performed after the centralization and at the beginning of information technologies integration.

SETTING

Two thousand two hundred beds university hospital, with medical, surgical, haematological, gynaecological, geriatric, paediatric oncological departments. Twelve thousand cancer chemotherapies each year.

METHODS

According to the failure modes, effects and criticality analysis (FMECA) method, the failure modes were defined and their criticality indexes were calculated on the basis of the likelihood of occurrence, the potential severity for the patients, and the detection probability. Criticality indexes were compared and the acceptability of residual risks was evaluated.

RESULTS

The sum of criticality indexes of 27 identified failure modes was 3596 for the decentralized phase, 2682 for centralization, 2385 for electronic prescription, 2081 for electronic production control, and 1824 for bedside scanning (49% global reduction). The greatest improvements concerned the risk of errors in the production protocols (by a factor of 48), followed by readability problems during transmission (14) and product/dose errors during the production (8). Among the six criticality indexes remaining superior to 100 in the final process, two were judged to be acceptable, whereas further improvements were planned for the four others.

CONCLUSIONS

Centralization to the pharmacy was associated with a strong improvement but additional developments involving information technologies also contributed to a major risk reduction. A cost-effect analysis confirmed the pertinence of all developments, as the cost per gained criticality point remained stable all over the different phases.

Concentration and bioavailability of fluoride in mouthrinses prepared in dispensing pharmacies

Considering the importance of medication quality control and that mouthrinses for dental caries prevention have commonly been prepared in dispensing pharmacies, this study assessed formulations containing 0.05% NaF acquired from 6 dispensing pharmacies in the city of Piracicaba, S.P. The mouthrinse formulations were purchased in 3 separate periods and coded from A to F. Fluoride ion (F-) concentration was determined in all formulations in the 3 periods, and in those acquired in the 3rd period, the bioavailability of fluoride with dental enamel with caries-like lesions and the pH of products were evaluated. A solution of 0.05% NaF and distilled deionized water were used, respectively, as positive and negative controls. In the bioavailability analysis, fluoride present in dental enamel was determined removing, by acid etching, two layers of enamel; fluoride in the acid extract was determined with a specific electrode. The mouthrinses prepared in 5 pharmacies presented a F- concentration close to the expected value, except for the product prepared in one of them, in which a mean of 0.01% NaF was found. All products were more efficient than the negative control (p<0.05) in terms of reactivity with dental enamel, but differences among them were observed with regard to the positive control (p<0.05). The data suggest that a quality control program should be implemented in dispensing pharmacies to guarantee the quality of fluoridated mouthrinses formulated.