Background Due to the toxicity of molecules involved and the seriousness of adverse drugs events, chemotherapy compounding is a high risk medical practice. To ensure high standards of safety and quality of the process, in September 2014 our hospital pharmacy developed a new oncology workflow, based on implementation of a robotic system for intravenous (IV) chemotherapy compounding. In order to avoid any mistakes that can lead to potential medication errors, the technology adopted was equipped with a set of different sensors able to guarantee the appropriate identification of the all components used for the compounding.
Purpose To present the improvement introduced by automation in terms of quality and safety of the cure offered to patients, highlighting the importance of a total controlled oncology workflow.
Material and methods We analysed 8 weeks of automated IV production, focusing on potential medication errors intercepted by the automated system. All of these events were recorded and processed by APOTECAmanager, the pharmacy IV production management software.
Results The 2 month production evaluation results in 2312 IV chemotherapies prepared were analysed. The automated system detected 59 potential medication errors, preventing any erroneous therapy compounding. In detail:
50 events associated with incorrect components barcode scanning (eg, sodium chloride instead of dextrose bag scanning);
5 occurrences during the vial weighing procedure;
4 episodes during the vial label identification.
All these events were related to incorrect material loading carried out by the technician. We assessed the weekly trend in potential error occurrences: Monday and Tuesday results were the highest frequency (7.1% and 6.2%, respectively, of total daily production). We also noticed that 51% of detected errors occurred between 8am and 11am in the morning.
Conclusion Every step in the oncology workflow is now totally controlled, allowing the traceability of each operation, from prescription to administration. The results showed the added benefit of this technology in terms of reduction of potential medication errors and self-assessment of your own compounding procedure; at the same time, evidences point out to the need for implementing specific interventions in clinical practice to reduce the probability of occurrence of these events.
No conflict of interest
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