Digital video control at the Centralized Unit of Chemotherapy Preparation: total security of the preparation process?
28 September 2021L. Josse(1), H. Cadart(1), A.Bianchi(1)
(1) Pharmacy Unit, Centre Hospitalier Intercommunal Nord Ardennes, Charleville Mézières, 45 avenue de Manchester, 08000 Charleville Mézières, France
We installed the Drugcam® tool in August 2020 within the Centralized Unit of Chemotherapy Preparation unit (CUCP) of our establishment in order to further secure the chemotherapy preparation process. This new tool should eventually replace the double visual inspection which is done by a third person. The goal of this study is to evaluate the implementation of the tool and the securing of the process after 6 months of installation. Analyze the errors encountered, their type and their impact.
After 6 months of installation, analysis of the rate of preparation made through Drugcam® compared to the total number of preparations made at the CUCP. Then, during 2 months, the number of errors noted and their type were analyzed through Drugcam® control. An Excel traceability was installed in order to register the “true” errors, that is to say the errors which do not correspond to a wrong detection from the video cameras.
From March 01, 2021 to May 01, 2021, 1,747 preparations were made on Drugcam in a total of 1,800 preparations, which represents 97%. At least one detection error was found on 387 preparations, which represents 22%. The types of errors were: invalid syringe presentation, detection of a wrong vial or administration package, non-respect of the scenario. Over these two months, only 3 « true » errors were founded, 2 of which were resolved during preparation. The last one was not noted at the time of production, so it had to be destroyed.
The deployment of Drugcam® is almost total except drugs under temporary authorization of use, in clinical trials or those requiring specific syringes. Of the 387 detection errors, less than 1% require a deep analysis by the pharmacist and correspond to a real preparation error. In fact, the others ones correspond to a wrong detection of syringes, vials or dilution solvents by the video camera. A closer analysis of these "true" errors highlights a new type of adverse event related to the tool. Indeed, in the case of the destroyed preparation, the pharmacy technician forgot to present the syringe filled with the product to the camera.
To avoid the problem, the pharmacy technician filled the syringe with an air volume to proceed to the next step. A feedback committee should be done to sensitize the manipulators so that this error does not happen again. It is planned that the pharmacist who does the control and dispensing of the preparations view the whole preparation to detect this type of error which cannot be recognized by the tool. Indeed, the coupling of the video recording is absolutely necessary in addition to the control by artificial intelligence to analyze this type of error which cannot be detected by the video camera.