Feedback about incidents on CHIMIO® software
2 October 2013Julien Duquesne, Nassir Mirfendereski, Rémy Collomp, Sandra Ruitort Service Pharmacie, Hôpital l’Archet,
CHU de NICE, France
The software CHIMIO® is a tracking tool for monitoring the chemotherapy circuit. Various incidents have been reported in medical equipment vigilance. The aim of this work is to collect incidents, identify their origins and provide corrective measures.
Incidents on CHIMIO® were recorded between 2010 and 2012.
9 types of incidents have been reported, 4 of them serious: errors in dose
calculation in multi-lines protocols, error in birth date, the disappearance of chemotherapy lines and errors in calculation when testing a software update. For multi-lines protocols, CHIMIO® reversed age and weight intervals. Corrective measures have been applied without any delay: pharmaceutical double check for multi-lines prescriptions, setting all multi-lines protocols (186) in single line protocols.
Children born in 2009 appeared to be born in 1909: this incident was solved with DLIMDATE setting update. The disappearance of prescription lines was caused by software micro cuts when generating following days: an update solved this problem too. When downloading a new software version, a
validation procedure is performed on test base prior to using it in production.
Other actions were implemented to ensure prescription safety: double pharmaceutical check for new protocols created in CHIMIO®, check pediatric doses from the paper version for all pediatric prescriptions, discussion about
CHIMIO® incidents during pediatric RMM.
Chemotherapy prescriptions computerization has not only advantages but also few risks. Incident management and medical equipment vigilance reports are compulsory to improve process security.