Controlled atmosphere area of errors: to learn otherwise

6 October 2017

J. Bellegarde1, R. Kimbidima1, R. Veillet1, S. Trevis1, V. Sautou2 1 CHU Clermont-Ferrand, Pôle Pharmacie, F-63003 Clermont-Ferrand, France
2 Université Clermont Auvergne, CHU Clermont Ferrand, CNRS, SIGMA Clermont,
ICCF, F-63000 Clermont-Ferrand, France


This simulation exercise was set up to raise awareness of the pharmacy technicians (PT) of our chemotherapy preparation unit to the risks of mistakes posed by different preparations and to enhance their continuous training.


2 half-day sessions (A1 and A2) were realized in order to involve a maximum of PT; one biological safety cabinet was dedicated to this activity. 13 (A1) and 15 mistakes (A2) were introduced throughout the 3 stages of the process: preparation of necessary items for manipulation, preparation of cancer chemotherapy admixtures and preparations’ control. Mistakes focused on identity, batch and peremption of drugs, solvents and medical devices, steps in the preparations’ realization and the final aspect and identification of preparations. At the end of the exercises the pharmacist resident did an individual correction and gave participants a written sum-up.


8 PT took part in the workout (4 by session); they dedicated about 30min to it. The team’s average score was 15.5/20 (18.1/20 for A1 and 13.3/20 for A2). 80.6% of mistakes about preparation of necessary items for manipulation were found, 77.8% of those concerning the implementation of the preparations and 75% of mistakes related to the control of the preparations.
The most rarely found errors were inadequate volume of leftover solution to realize the preparation, upside down plasticized drape and utilization of an expired leftover solution.
100% of the PT were satisfied with this exercise and wanted to do it again.


This concept was welcomed by the PT who liked the recreational and innovative nature of the exercise that will be reiterated. Pharmacists did an important preparatory work for its implementation, which requested a rigorous organization.
Some mistakes unintentionally introduced were found by the PH: an increased vigilance and a more meticulous check before the exercise will be necessary during the organization of the next sessions.

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