Spot the error !

E.Seguin, M.Friou, T.Genevee, C.Seara, E.Peyrilles, C.Giard, I.Ferry, M.Lafay, L.Escalup Pharmacie Institut Curie, 35 rue Dailly 92210 Saint Cloud

Aims

The anticancer drugs preparations of our chemotherapy preparation unit are controlled by a visual double-checking. Recently, some errors escaped this control. To improve both the quality of preparation and of our training process, we organized a simulation workshop providing errors in preparation, in order to raise staff awareness to the risks of such errors related to preparation and to provide a continuum in the learning experience and professional development of participants.

Method

10 preparations were submitted to be checked 22 qualitative control errors were introduced. These included the solvent, the medical devices (pipe, syringe …), the dose, and the final aspect- issues identified in our daily record of non-compliance. The workshop took place over 3 half-days. Each person had 20 minutes to identify the errors by verifying the preparation against the artificial chemotherapy manufacturing sheet. Each participant was previously trained to the visual double-checking. The errors were quoted as “major” (impact on the patient or the stability of preparation) or “minor” (impact on the use of the preparation).

Results

Fourteen people out of 17 participated in the workshop (3 pharmacists, 1 manager, 9 pharmacist technicians and 1 pharmacist resident). On average, 19 errors out of 22 were identified (86 %) (min=13,max=22). The 8 major errors were identified by 86 % of the participants: nature and volume of the solvent errors were all detected; final visual aspect’s unconformities (3 errors of product) were identified by 76 % and the 2 dose’s anomalies (incorrect volume) by 79%. The minor errors were identified by 86 % of participant.

The most frequently spotted errors were: lack of opabag (100 %), unsuitable pipe and/or syringe (96 %) and pipe not clamped (93 %).

Some errors introduced involuntarily were also identified.

Discussion/conclusion

These good results should be qualified because the workshop was not in real condition and therefore the team’s focus was probably increased and show that the team is efficient and benefits from good initial training. At the end of this exercise, individual feedback and a collective synthesis of the anonymous results was presented to the team.

This workshop was appreciated and welcomed by the whole team. It will be used during initial training to final preparation control of new pharmacist residents or technicians.

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