Pharmacy Department, Geneva University Hospitals, Geneva, Switzerland.
Institute of Pharmaceutical Sciences of Western Switzerland, School of Pharmaceutical Sciences, University of Geneva, Geneva, Switzerland.
J Oncol Pharm Pract. 2023 Dec;29(8):1868-1877. doi: 10.1177/10781552231152145. Epub 2023 Feb 7.
We used an educational healthcare simulation tool called room of errors (ROE) to raise pharmacy operators' awareness of potential errors in a chemotherapy production process and assessed its impact on their knowledge and satisfaction.
Twenty-five errors (compiled from internal procedures, literature and our hospital's reported incidents) were categorised as static ( = 7, visible by the participant anytime) and dynamic ( = 18, made by a pseudooperator in front of the participant). Our simulated cytotoxic production unit (CPU) hosted the 1 h-simulation. Two pharmacists (supervisor/pseudo-operator) welcomed the trainee for a 10-min briefing. During the 20-min simulation, participants watched the pseudo-operator's gestures in a simulated chemotherapy production process. Participants called out each error observed (recorded by the supervisor). A 20-min debriefing followed. ROE's impact on knowledge was measured through participants' answers to a before-and after 18-item questionnaire about CPU's procedures and certainty about answers on a scale (0%-100%). Participants evaluated the training using a satisfaction questionnaire (Likert scale, 1-6).
The 14 participants detected 70.4% ± 11.4% of errors. Least-detected errors were "using non-disinfected vials" (42.9%) and "touching syringe plunger" (0%). Critical errors (expired leftovers or glucose instead of sodium chloride) were detected at 57.1%. Knowledge improved from 60.3% to 94.1% (p < 0.001) and certainty from 75.3% to 98.8% (p < 0.001). Participants appreciated this non-judgmental, informative, and original training (satisfaction 95.7%). Some pointed out difficulties settling into the game quickly and visualising static and dynamic errors simultaneously.
This ROE simulation improved operators' knowledge and certainty. Longer-term testing should be done to measure knowledge retention over time.
我们使用了一种名为“错误房间”（ROE）的教育医疗模拟工具，旨在提高药剂师在化疗生产过程中潜在错误的意识，并评估其对他们的知识和满意度的影响。
从内部程序、文献和我们医院报告的事件中，共收集了 25 个错误，分为静态（ = 7，参与者随时可见）和动态（ = 18，由伪操作员在参与者面前完成）。我们的模拟细胞毒性生产单元（CPU）举办了 1 小时的模拟。两名药剂师（主管/伪操作员）欢迎学员参加 10 分钟的简介。在 20 分钟的模拟过程中，参与者观察伪操作员在模拟化疗生产过程中的手势。参与者观察到的每个错误都会大声说出来（由主管记录）。随后进行了 20 分钟的讨论。ROE 对知识的影响通过参与者对 CPU 程序的前测和后测 18 项问卷的回答以及对答案的确定性（0%-100%）来衡量。参与者使用满意度问卷（李克特量表，1-6）对培训进行了评估。
14 名参与者发现了 70.4%±11.4%的错误。检测率最低的错误是“使用未消毒的小瓶”（42.9%）和“触碰注射器活塞”（0%）。发现了 57.1%的关键错误（过期的剩余物或葡萄糖代替氯化钠）。知识从 60.3%提高到 94.1%（p < 0.001），确定性从 75.3%提高到 98.8%（p < 0.001）。参与者非常欣赏这种非评判性、信息丰富且具有创意的培训（满意度为 95.7%）。一些参与者指出，他们很难快速适应游戏，并且很难同时看到静态和动态错误。
ROE 模拟提高了操作人员的知识和确定性。应该进行更长期的测试，以测量随着时间的推移知识的保留情况。
