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4CPS-158 Evaluation of medicine-related incidents in the National Bone Marrow Transplant Centre
  1. R Aouinti1,
  2. I Ellouze1,
  3. S Ben Hassine1,
  4. I Fazaa1,2,
  5. L Achour1,2,
  6. C Drira1,3
  1. 1National Bone Marrow Transplant Centre, Pharmacy Department, Tunis, Tunisia
  2. 2Faculty of Pharmacy, Pharmaceutical Sciences A, Monastir, Tunisia
  3. 3Faculty of Pharmacy, Pharmaceutical Sciences B, Monastir, Tunisia


Background and importance The Sterile Compounding Centralised Unit (SCCU) at the National Bone Marrow Transplant Centre (NBMTC) prepares an average of 9000 sterile injectable preparations yearly. Many medicine-related incidents (MRI) with various levels of therapeutical and economic repercussions have been documented either in the clinical or the pharmacy departments.

Aim and objectives Evaluation of MRI in the NBMTC and economic analysis of medication losses.

Material and methods An 8-month retrospective study from January to August 2021. A MRI incident sheet was elaborated to document each incident for data collection and analysis.

Results A total of 35 incidents were reported during the study period. The main causes were: stopping the drug prescription by the treating doctor without informing the pharmacist in charge (42.85%), medication administration omission by the treating staff (20%) and cold chain breach (11.42%).

Of the 242 medication units’ loss (instability after compounding or cold chain breach), the pharmacy department is responsible of 69.8% of losses, of which 98.8% were caused by the cold chain breach. The adult haematology department is responsible of 22.7% of the total units’ loss whereas 7.4% of the losses are attributed to the paediatric haematology department. The most involved drug families in these incidents are anticancer drugs (45%) and antifungal drugs (20%). 43.3% of the MRI are non-hospital nomenclature drugs.

The cost evaluation of the incidents revealed a loss of an equivalent of €37 615 representing 2.06% of the total medicines budget of the NBMTC and 3.2% of the sterile preparations prepared by the SCCU. An 85.9% cost loss was caused by a technical error in the NBMTCT power monitoring system.

Conclusion and relevance Establishing corrective solutions such as optimising medicine conservation and supply chain quality limits the occurrence of further MRI. The first step towards a more pertinent improvement in the prevention of the occurrence of further MRI is the total digitalisation of patient files.

Conflict of interest No conflict of interest

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