Set up of a mistakes isolator in the cytotoxic drug reconstitution unit (CDR)

4 October 2018

L.Decarout, T.Gailland, G.Viard-Gaudin, P.Barbeau, I.Federspiel A.Lemoigne, P.Bedouch CHU de Grenoble, boulevard de la chantourne, 38700 La Tronche, France.


By similarity with mistakes room (dummy patient room with risky situations, used for educational purpose) [1], we set up a mistakes isolator in the CDR. This practice is part of a continuous training approach for pharmacy technician to evaluate good practices of chemotherapy preparations.


Three differents situations including 3 types of mistakes (validation of elements composing the plate before preparation, validation of the preparation itself, and working environnement) were created. Every situation contains 10 mistakes. Each technician, individually evaluated, tells the pharmacist the mistakes detected and suggests a solution. Eventually an assessment is given, with an explanation of the mistakes.


All technicians of the CDR were evaluated (n=9). The results (average = 6,2/10), are similar as those in the available datas [2]. The mistakes type "validation of plates" (for example a different concentration of vials from the protocol) are mostly identified (17/24), same for "validation of preparation" (27/45). "working environnement" mistakes (inappropriately preserved opened vials or with date of reconstitution not indicated...) are less identified (10/21).


The mistakes with potential clinical consequences for the patient are detected. The mistakes not identified mostly have a financial impact. However, during the debriefing, it was reminded that the analyze of working environnement is very important to avoid confusion (the least identified mistake is the presence of vials in workplan unrelated to the preparation). The technicians appreciated the exercise. The mistakes isolator will be done regularly. Other risk situation can be considered, for instance, a vial breakage simulation.

[2J Oncol Pharm Pract. 2017 Jan. A "chamber of errors" adaptation to assess pharmaceutical assistants’ knowledge in chemotherapy preparation. Loboda C et al

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