Cotteret Camille, Marry Stéphanie, Loeuillet Richard, Videau Margaux, Cisternino Salvatore, Schlatter Joël
1 Service Pharmacie, Hôpital Universitaire Necker-Enfants Malades - APHP, Paris, France.
2 Inserm UMR-S 1144, Team "Blood-brain barrier in brain pathophysiology and therapy", Université Paris Descartes, Paris, France.
J Oncol Pharm Pract. 2019 Jul;25(5):1187-1194. doi: 10.1177/1078155218821426. Epub 2019 Jan 9.
The risk of medication errors related to drug preparation unit cannot be totally avoided because of human interference. The aim of this study is to investigate the background and knowledge of the pharmacy staff by replicating the cytotoxic preparation unit with potential errors.
A 10-m room was provided to duplicate the centralized chemotherapy unit with three areas reproducing virtually the equipment preparation bench, the isolator, and the dispensing bench. The 14 situations selected by experts were integrated to each corresponded area. For each participant, a form was given and answers were analyzed by two independent experts. Statistical processing data were performed using GraphPad Prism® software.
A total of 19 professionals participated in error simulation workshop over a one-month period. The overall rate of correct responses was 58 ± 19%. In five situations, correct responses rate was lower than 50%: wrong drug batch related to the preparation sheet (40%), inappropriate sterilizing conditions (15%), the time on the preparation sheet provides an expired expiry date for melphalan preparation (45%), a maximum drug dose exceeded (25%), the dispensing form not corresponds to the preparation sheet and final product label (30%). The rate of correct responses was 45 ± 25% for professionals not specifically dedicated to chemotherapy preparation. The overall satisfaction workshop rate was 8.7 ± 1.0 out of 10.
This study showed the importance of training programs to sensitize personal staff to the risks of chemotherapy preparation and prevent errors.
由于人为干预，与药物配制单元相关的用药错误风险无法完全避免。本研究的目的是通过模拟存在潜在错误的细胞毒性药物配制单元，来调查药房工作人员的背景和知识。
提供一个10米长的房间来复制集中化疗单元，设有三个区域，分别模拟设备准备台、隔离器和调配台。将专家选择的14种情况整合到每个相应区域。为每位参与者提供一份表格，由两名独立专家分析答案。使用GraphPad Prism®软件进行统计处理数据。
在一个月的时间里，共有19名专业人员参加了错误模拟研讨会。正确回答的总体率为58±19%。在五种情况下，正确回答率低于50%：与配制单相关的药品批次错误（40%）、灭菌条件不当（15%）、配制单上的时间显示美法仑配制的有效期已过（45%）、超过最大药物剂量（25%）、调配单与配制单及最终产品标签不符（30%）。非专门从事化疗配制的专业人员的正确回答率为45±25%。研讨会的总体满意度为8.7±1.0（满分10分）。
本研究表明培训计划对于提高工作人员对化疗配制风险的认识和预防错误的重要性。
