Back to Paper Age: Fake cyberattack / Real production – Real-world exercise in the CRU (Cytotoxic Reconstitution Unit) and the Day Hospital

Introduction
Computer science is integral to chemotherapy production. Since cyberattacks targeting healthcare facilities are becoming increasingly frequent, a robust Activity Continuity Plan (ACP) is essential to ensure continuity of care. The aim of conducting a full-scale exercise was to test the ACP and prepare staff to implement it safely.

Materials and methods
A reduced patient schedule was planned in collaboration with the day hospital. During the exercise, CHIMIO^® software was intentionally disabled, with the option to restore access immediately if patient safety was compromised. Following a briefing on the contingency tools (including paper patient records, an Excel^®-based compounding worksheet generator, and a prescription template, all stored on a USB drive), pre- and post-exercise questionnaires were completed by one secretary, four physicians, two nurses, two pharmacy technicians, one supply technician, and one pharmacist, to evaluate several criteria on a scale of 0 to 4. Organizational metrics and production timelines were recorded before and throughout the exercise and subsequently compared with routine practice.

Results
Under routine conditions, the CRU manages approximately 20 patients per day, corresponding to around 30 chemotherapy preparations delivered in seven trips to day hospital, located 250 metres from the CRU. The ACP lasted 4 hours, for a reduced schedule involving 12 patients. 24 chemotherapy preparations were produced for the 10 patients who ultimately received treatment. Retrieving and printing patient records required 1 hour and 15 minutes of pharmacist and pharmacy resident time. Despite an increase from 7 to 15 trips between CRU and day hospital, no meaningful impact on production timelines was observed. The CHIMIO^® software did not require reactivation. One error occurred during the exercise: incorrect administration times were assigned to three 5-fluorouracil preparations since injection times for boluses and infusion cassettes were not distinguished on the compounding worksheet. The discrepancy was detected during the pharmaceutical validation process and corrected before drug release. Questionnaire results demonstrated improved understanding of the ACP (1.3 vs. 3.1/4) and increased confidence in managing a cyberattack (2.0 vs. 3.1/4). Concern about a potential cyberattack decreased slightly (2.6 vs. 2.3/4). Participants rated the exercise as highly valuable (3.6/4) and the contingency tools as appropriate and effective (3.2/4). All participants expressed willingness to take part in similar exercises in the future.

Discussion
Beyond validating the ACP, the exercise familiarized healthcare professionals with contingency procedures and confirmed several operational weaknesses, including the distance between the CRU and the day hospital, the need for two pharmacists to ensure workflow continuity, and the importance of maintaining up-to-date documentation. The exercise also led to the implementation of several corrective measures, including the introduction of a checklist, systematic double-checking of compounding worksheets, regular updating of reference documents, and verification of the completeness of patient records (allergies). Effective multidisciplinary communication proved essential to maintaining safe and efficient chemotherapy production. Although conducted under simulated conditions and despite its limitations, this full-scale exercise serves as a valuable tool to evaluate the ACP under real-world conditions and to strengthen the team’s preparedness for cyber risks.

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