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

Advanced prescription of injectable anticancer drugs: Safety assessment in a European Comprehensive Cancer Centre using the risk matrix approach

AIMS

The purpose of this work was to assess failures in the advanced prescription of parenteral anticancer agents in an adult day oncology care unit with more than 100 patients per day.

METHODS

An a priori descriptive analysis was carried out by using the risk matrix approach. After defining the scope in a multidisciplinary meeting, we determined at each step the failure modes (FMs), their effects (E) and their associated causes (C). A severity score (S) was assigned to all effects and a probability of occurrence (O) to all causes. These S and O indicators, were used to obtain a criticality index (CI) matrix. We assessed the risk control (RC) of each failure in order to define a residual criticality index (rCI) matrix.

RESULTS

During risk analysis, 14 FMs were detected, and 61 scenarios were identified considering all possible effects and causes. Nine situations (15%) were highlighted with the maximum CI, 18 (30%) with a medium CI, and 34 (55%) with a negligible CI. Nevertheless, among all these critical situations, only three (5%) had an rCI to process (i.e., missed dose adjustment, multiple prescriptions and abnormal biology data); the others required monitoring only. Clinicians' and pharmacists' knowledge of these critical situations enables them to manage the associated risks.

CONCLUSIONS

Advanced prescription of injectable anticancer drugs appears to be a safe practice for patients when combined with risk management. The major risks identified concerned missed dose adjustment, prescription duplication and lack of consideration for abnormal biology data.

Implementation of the failure modes and effects analysis in a Hospital Radiopharmacy Unit

AIM

The aim of this study is the implementation in a Hospital Radiopharmacy Unit of a risk analysis methodology in order to proactively identify possible failure modes and prioritize corrective measures.

MATERIALS AND METHODS

By means of the failure modes and effects analysis (FMEA), the possible failure modes of each of the stages of the processes of prescription, preparation, and administration of radiopharmaceuticals for diagnostic and therapy were identified. From the variables of severity, probability and detectability, the risk was quantified using the Risk Priority Number (RPN) for each failure mode, sub-process, and type of radiopharmaceutical. Improvement measures were established and the reduction in the RPN value was calculated.

RESULTS

A total of 96 failure modes were identified (58 for diagnostic radiopharmaceuticals and 38 for therapy). Biunivocal identification of the patient with the radiopharmaceutical is the failure mode with the highest RPN (60) and the radiolabeling cell sub-process the one that has the highest risk (RPN 286). As a result of the improvement measures, the overall RPN was reduced by 22% for diagnostic radiopharmaceuticals and 20% for therapy. This reduction would be 46% and 31% respectively if radiopharmacy software and a barcode technology in the administration were implemented.

CONCLUSIONS

The application of the FMEA methodology as a risk analysis tool allows to identify the critical points of the processes related to radiopharmaceuticals and prioritize measures to reduce the risk.

Compounding in Ukraine: Assessment of the Risks for the Ointment’s Quality by the FMECA Method

The level of compounded medicines (CM) quality has always been questioned in different countries. This problem has been resolved by the introduction of quality assurance system (QAS) standards. One of its main areas of significance is the risks assessment process, which is especially important for the compounding pharmacy according to the requirements of different international documents. Since ointments constitute a large part of CM, quantity assessment of risks for their quality by the FMECA method has been completed. During the first step of the research, 42 potential deviations of compounded ointments (CO) quality were identified. Via the questioning of compounding pharmacies specialists in different regions of Ukraine by a pre-developed ten-point scale, the severity of deviations consequence, their occurrence probability, and detecting possibility were determined followed by the calculation of the priority risk number (PRN) value. The Pareto analysis showed that nine possible CO quality defects represented 21% of their total number. Defects related to the composition or technology of ointments (29%) and their compliance with microbiological purity requirements (23%) had the largest percentage contribution to the total PRN value. It was also found that the deviations consequence had the most serious impact on the CO quality, due to their direct influence on patient health.

Using failure mode and Effects Analysis to increase patient safety in cancer chemotherapy

BACKGROUND

Medication errors may occur during chemotherapy and can have fatal consequences. Healthcare Failure Mode and Effects Analysis (FMEA) is a method used to detect potential risks and prevent them.

OBJECTIVE

Aim of this study was to evaluate the medication process of intravenous tumor therapy in order to guarantee a high standard of patient safety.

METHODS

The main part of the study was performed at the University Hospital of Bonn, Germany. After assembling a multidisciplinary team, the individual steps of prescription, compounding, transport, and administration of chemotherapy were mapped in a flow diagram. The possible failures were identified and analyzed by calculating the risk priority numbers (RPNs). Finally, corrective actions were developed and after hypothetical implementation re-analyzed to measure their effects on the process. Subsequently, a shortened FMEA based on the catalogue failure modes developed in Bonn was carried out at the University Hospital of Cologne in order to evaluate its transferability to another hospital.

RESULTS

A total of 52 potential failure modes was identified in Bonn. Relating to the RPNs the most critically steps in the process were associated with the prescription, namely, incorrect information about individual parameters of the patient; non-standardized chemotherapy protocols; and problems related to supportive therapy. A significant risk reduction for most of the failure modes was assessed by implementing suitable corrective actions. The shortened FMEA in Cologne led to a different ranking of failure modes.

CONCLUSION

The implementation of this analysis has not only identified various safety gaps, but also shows how patient safety during chemotherapy can be enhanced. Moreover, it has sensitized the practitioners to failure modes potentially occurring in their work routine.

Virtual reality teaching in chemotherapy administration: Randomised controlled trial

AIMS AND OBJECTIVES

This study examined the effect of virtual reality (VR)-based documents (VRdocs) on knowledge and attitude towards chemotherapy administration in nursing students.

BACKGROUND

Chemotherapeutic drugs in cancer patients are a complicated and dangerous process. However, despite the high toxicity of the chemotherapeutic drugs, the compulsory or internship courses in nursing schools do not include training in operational chemotherapeutics and its associated safety measures.

DESIGN

A randomised controlled trial based on the CONSORT 2010 guidelines (registry number: NCT03707210).

METHOD

A total of 77 students were randomised to an experimental (VRdocs, n = 38) or a control group (n = 39). Pre- and posttest data were collected. After the pretest, the control group received the education documents, whereas, the experimental group used VR software consisting of an application about chemotherapy administration. Finally, the effectiveness of the intervention was self-evaluated using questionnaires after 7 days.

RESULTS

The posttest scores for knowledge (F = 6.412, p = .013) and attitude in the experimental group were significantly different from those in the control group (F = 8.469, p = .005). Compared with the control group, a significant number of students in the experimental group indicated their higher recommendation score for the VRdocs (p = .0001).

CONCLUSION

Schools must provide a variety of handouts and teaching methods to educate nursing students about high-risk nursing techniques. Methods using VR can address the shortcomings of the traditional documents, and the use of both methods simultaneously can produce better learning results.

RELEVANCE TO CLINICAL PRACTICE

Virtual reality based documents were provided to the participants to understand the preparation, implementation, and safety of chemotherapy. VRdocs allow students to re-learn high-risk care techniques without the influence of time and space and may prove useful for other nursing courses.

Risks associated with the evolution in the compounding process of parenteral nutrition solutions: use of the “FMECA” method

Objectives

An audit of the practices of our compounding unit was performed in 2016: areas of improvement were proposed, such as the automatization of our process. An automated compounder was acquired (MediMixmulti® MF4120R). The aim of the study was to anticipate the risks of the new process, in order to improve its security and to support the professionals during this evolution of our compounding process.

Methods

The Failure Modes, Effects and Criticality Analysis (FMECA) method was carried out in order to detect potential failures brought by the automatization of parenteral nutrition (PN) manufacturing in the new process. The FMECA method included four steps that were divided into five work sessions of one and a half hour each over a period of two months. A working group made up of professionals involved in the PN production process was set up (pharmacists, pharmacy resident, manager and pharmaceutical technician).

Results

Fifty failure modes were determined by this analysis, of which 96% could have an impact on the patient, 90% on the health staff and 74% on the product. The FMECA shows that 18 failure modes have a tolerable or unacceptable CI (CI≥100) for which it is necessary to implement preventive measures as a priority. This work also made it possible to review the barrier measures already in place for the current process.

Conclusions

The risk analysis allowed us to analyze the failures of both the actual and the future manufacturing processes. Once the most critical failure modes were identified, specific recommendations were proposed and an improvement plan was established. First, the compounder needs to be fully qualified. Then, the quality manual of the PN process will be reviewed and updated. Once these steps are completed, the pharmacy professionals (pharmacists, pharmacy technicians) will be trained and the PN production will be performed using the automated compounder on a daily basis.