An isolator of errors: a useful training tool for hospital technicians

7 October 2016

M. Moine, J.C. Nicoulaud, C. Roux, D. Sankhare, P. Faure, N. Jourdan Saint-Louis Hospital, anticancer preparation unit, 75010 Paris, France

To improve best practices cytotoxic preparation of hospital technicians, an isolator of errors was implemented.

An isolator was use during half a day. A pharmacist and a referent technician introduce 25 errors concerning 3 specific steps: materiel for preparation incoming in the isolator (4 preparations), preparation ready to make (2), finish preparation (4).

Mistakes were: physic-chemical incompatibility (PCI), expiration date, clamp, opabag®, doses, molecule identity, and medical devices. Hospital technicians had wrong manufacturing sheets from Chimio® based test and material for preparations. Hospital technicians were assessing by the pharmacist and the referent technician. There were costumed restitutions.

14 technician’s pharmacists have been involved. Mean score is 15,7/20, standard deviation is 2,2, median score is 15,4/20. 11/25 mistakes (44 %) were identified by all the team and 5/25 were identified by less than half.

PCI, preparations photosensitivity and chemical contamination of a sterile drape have been fully noticed. Nevertheless, some errors still masked:

  • Vincristine dose greater than 2 mg (only 1 technician identified)
  • Melphalan preparation out of date (5 technicians identified)
  • A colorless preparation of doxorubicin (2 didn’t identified)
  • A rest outdated (2 didn’t identified)

Moreover, only one out of two have noticed that a sterile drape has been installed upside down.

The implementation of this exercise needs a great investment and a rigorous check. Main difficulty was repeatability, for example: unclamping of tubing, bag containing preparations damaged. All the team enjoys this exercise and it will be reproduced once a year. It is now included in technicians training.

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