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PS-062 A playful approach to improve safety of the preparation process in a centralised pharmaceutical unit for chemotherapy drugs
  1. J Martin,
  2. O Ribes,
  3. A Sainfort,
  4. I Lefort
  1. Centre Hospitalier d’Ardèche Nord, Annonay, France


Background Medication errors in oncology are known to cause serious iatrogenic complications. Over time, pharmacy technicians handling cytotoxic agents become less attentive to potential errors that can occur during the fabrication process. A simulation tool called ‘Room of errors’ has shown its utility to raise awareness of healthcare professionals to potential risks in their everyday work.1

Purpose The aim of our study was to heighten awareness of technicians to major potential errors during preparation.

Material and methods The pharmacist and the resident compiled a list of the main potential errors with a criticality level attributed to each one. Each manipulator spent 15 min in the atmosphere controlled area and wrote down every error they noticed; the answer sheet was anonymous. The results were analysed and presented to the pharmacy technicians during a staff meeting. When required, some reminders were done by the pharmacist and resident, especially for high risk errors.

Results 6 of the 7 technicians working in our unit participated. The results are shown in the table.

Conclusion The experience has been very appreciated: the simulation is a good tool to identify and manage risks in a playful way, without accusations among participants. Reminders have been done to staff, especially on the importance of verification of expiration dates. The next step of our work is to assess whether this simulation programme would help prevent medication errors with a second simulation in the next 6 months.

References and/or acknowledgements 1. Oriol P, Fortier E, Grenier D. The room of errors, fun and pedagogical. Revue De L’infirmière2016;221:33–4. doi:10.1016/j.revinf.2016.02.014

No conflict of interest

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