Error simulation in a centralized cytotoxic unit

6 October 2017

M. Laffite, S. Biscarat, I. Grangé Centre Hospitalier Emile Roux, Service pharmacie,
12, Boulevard du Docteur Chantemesse, 43000 Le Puy-en-Velay, France


Our Centralized Cytotoxic Unit (CCU) produce annually over 9000 injectable chemotherapy. The team includes a pharmacist, two pharmacy technicians and a storekeeper. Preparations are made under isolator. An error simulation has been created to improve the risk management of the process as part of continuous training of the staff.


  • Raise awareness of the personal on adverse and unexpected events which can occur.
  • Ensure a continuous training of the staff.

Material and Method

In the Controlled Atmosphere Area, 11 errors have been installed, regarding pharmaceutical validation process, chemotherapy preparation and final dispensation. According to our risk mapping in the CCU, error gravity was rated from 1 (very low) to 4 (very high). Four errors of level risk 4 were installed. Every staff member was given 20 minutes to find the errors and 10 minutes to debrief about it. A collective and anonymous feedback was realized.


12 persons took part in this experience (3 pharmacists, 7 pharmacy technicians, 2 storekeepers). Only two persons were able to detect 100% of the errors. The worst result we had was the ability of the person to detect only seven errors. Out of four level risk 4 errors:

  • two were always detected
  • one was detected in 75% of the simulations
  • the last one was detected in only 50% of the simulations
    Also one error of level risk 1 was found in 25% of the simulations.

Discussion and conclusion

Those simulations have proven the need of continuous training and the importance of constantly re-assessing the staff. At the end of the simulation, a point was made about the errors and the risk. The simulator achieved a personal and collective reflection. Those who took part in the experience enjoyed it. Another error simulation will be organized, with new errors.

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