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5PSQ-052 The error room: a fun training tool for the pharmaceutical chemotherapy unit
  1. M Jaffuel,
  2. J Mangavelle,
  3. S Vernardet,
  4. I Lefort
  1. Centre Hospitalier D’ardèche Nord, Pharmacie, Annonay, France


Background A significant part of hospital activity is now dedicated to the handling of oncology, and the chemotherapy production by the pharmacy is an essential stage. This activity is still currently human-dependent and one error can therefore have serious consequences. Through a ‘room of errors’, a participating training in real-work conditions can improve ongoing staff training and the security of this cytotoxic production path.

Purpose To evaluate the critical capacity of the pharmacy technicians to track the major deviances in the preparation of injectable anticancer drugs.

Material and methods A list of errors was established by the pharmacist and the resident and then implemented in the controlled atmosphere zone. A level of criticality had been assigned to each error. The usual technicians and pharmacist could participate in this ‘room of errors’. The time left to find errors was 15 min by participants. An information sheet was filled anonymously. In the following days, an error analysis and debriefing were conducted to discuss the most critical errors.

Results The six usual technicians and one pharmacist participated in this ‘room of errors’. Fourteen errors were distributed in the area. On average, 7.7 errors out of 14 total errors were discovered by the seven participants. Four out of seven participants reported 50 per cent or fewer errors. Nine errors out of 14 were classified as high criticality level. For these nine high criticality errors, one error was not found by any of the participants, four errors by less than five participants and three errors by all participants. Only one-third of this category of high-risk error was detected by all manipulators.

Conclusion It was the second time we had this experience. This ‘room of errors’ is a fun way to train staff to minimise and prevent potential errors related to the production of chemotherapy. It is also an opportunity to provide reminders of good manufacturing practices. In view of the results, it would be interesting to continue training by this approach or other learning process such as e-learning. This would maintain and bring new knowledge to pharmacy technicians to ensure the safety of the patient in their care process.

References and/or acknowledgements No conflict of interest.

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