The Errors Tray: a simulation tool for evaluating professional practices in a chemotherapy production unit

28 September 2021

Tristan Rubin1, Clément Cappelier1, Florine Chollet1, Sonia Mitreski1, Victor Massot1, Chloé Plichon1, Virginie Andre1, Xavier Pourrat2
1 Oncological Clinical Biopharmacy Unit, CHRU Tours, France
2 Trousseau Pharmacy, CHRU Tours, France

The preparation of the trays containing the material necessary for the preparation of chemotherapy is the first step in the cytotoxic manufacturing circuit. This is a fundamental step in the process where a platter error could lead to a manufacturing one. Following a number of nonconformities in the preparation of the stage notified over the year, it was decided to create a simulation tool for the platter errors. The aim is to evaluate staff’s knowledge using this tool and to put in place targeted improvement actions to reduce tray nonconformities.

The errors tray was created on the basis of 9 kits, in which we intentionally put between 0 and 9 errors. They are representative of different difficulty level in daily preparations. Three serious errors that could have an important impact on the patient were introduced in different kits. Each one of them contains a scenario, a patient label, a manufacturing and preparation sheet’s screenshot tray extracted from Chimio® software, and equipment. This error containing kit was presented to all the staff, with the instruction to realize it alone without any time limit. The participants’ results were collected in an Excel® file with the following data: professional status, number and type of error per tray.

In the space of two months, thirty-one unit workers participated: pharmacists, interns, pharmacy technicians, and professional workers (PO). The average error rate per participant was 32.52%, and the error rate per kit ranges from 7.41% to 64.71%. The OPs who achieved more trays on a daily basis without doing the preparations have an average error rate scale of 48.46%. They made more mistakes choosing syringes (28.05%), active principal vials (24.08%), containers (21.5%), small items like forgetting the connecting material (18.55%) and choosing the wrong kind of manifolds (7.82%). Generally across the staff, and among the 3 main/serious errors; the outdated active principal vial was seen in 40% of cases, the intrathecal syringe error was seen in 84% and the solvent error in 53%.

This study highlights gaps in the equipment knowledge adapted to the trays preparations. In the light of those results, many actions were put in place: necessary material check-lists were created for the 15 trays identified as complex. All material storage has been labeled to stop any risk of confusion between them. A ‘Tray Guide’ for the staff is being created, and will include the basic information and required knowledge on the equipment and cytotoxic preparations. Finally, a routine evaluation will be set up after the new staff’s training by the error tray method.

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