Impact of robotic antineoplastic preparation on safety, workflow, and costs

Automated preparation of chemotherapy: quality improvement and economic sustainability

PURPOSE

The quality and economic implications of manual versus automated preparation of antineoplastic drugs were compared.

METHODS

This four-week study evaluated 10 routinely used antineoplastic drugs (fluorouracil, cyclophosphamide, gemcitabine, trastuzumab, bevacizumab, oxaliplatin, cisplatin, paclitaxel, irinotecan, and etoposide) prepared by manual and automated procedures. The accuracy of the dose of the active ingredient was calculated in terms of percent relative error for the difference between the nominal value indicated on the prescription and the actual value of the drug in the finished product. A comparative economic analysis of the manual and automated preparation procedures was performed by calculating the mean unit cost for each preparation at different production levels. Participating pharmacists and technicians completed a survey rating each preparation method in terms of performance, operator satisfaction, technology, and safety.

RESULTS

Of the 2500 i.v. antineoplastic preparations made in the pharmacy during the four-week study period, 681 were analyzed (348 using the automated procedure and 333 manually). Of these, 17 varied by more than 5% of the prescribed dose, and 1 varied by over 10%. Accuracy, calculated in terms of average percent relative error, was the highest and lowest during manual preparation. The preparation time for individual drugs was always higher when prepared using the automated procedure. A lower mean variable unit cost was observed for preparations made using the automated procedure. Questionnaire results revealed that operators preferred the automated procedure over the manual procedure.

CONCLUSION

Both the automated and manual procedures for preparing antineoplastic preparations proved to be accurate and precise. The automated procedure resulted in substantial advantages in terms of quality maintenance standards and risk lowering.

Environmental contamination by cyclophosphamide preparation: Comparison of conventional manual production in biological safety cabinet and robot-assisted production by APOTECAchemo

Objectives

The aim of this study was to compare environmental contamination of cyclophosphamide (CP) during 1 week of drug compounding by conventional manual procedure in a biological safety cabinet (BSC) with laminar airflow and a new robotic drug preparation system (APOTECAchemo).

Methods

During four consecutive days, similar numbers of infusion bags with cyclophosphamide were prepared with both techniques in a cross-over design. Wipe samples (49 for BSC, 50 for APOTECAchemo) were taken at several locations (gloves, infusion bags, trays, BSC-benches, floor) in the pharmacy and analyzed for CP concentrations by GC-MSMS (LOD 0.2 ng/sample).

Results

The detection rate was 70% in the BSC versus 15% in APOTECAchemo. During manual preparation of admixtures using BSC contamination with CP was below 0.001 ng/cm2 at most locations, but significant on gloves (0.0004–0.0967 ng/cm2) and the majority (70%) of infusion bags (<0.0004–2.89 ng/cm2). During robotic preparation by APOTECAchemo, gloves (1 of 8: 0.0007 ng/cm2) and infusion bags (3 of 20: 0.0005, 0.0019, 0.0094 ng/cm2) were considerably less contaminated. Residual contamination was found on the surfaces under the dosing device in the compounding area (0.0293–0.1603 ng/cm2) inside the robotic system.

Conclusions

Compared to outcomes of other studies, our results underline good manufacturing procedures in this pharmacy with low contamination for both techniques (BSC and APOTECAchemo). Comparison of both preparation procedures validated that contamination of infusion bags was much lower by using the robotic system.

Assessment of final product dosing accuracy when using volumetric technique in the preparation of chemotherapy

BACKGROUND

Studies have compared gravimetric and volumetric dosing accuracies in chemotherapy agents, finding high accuracy in gravimetric measurements with a mean deviation of ± 0.06%, while volumetric measurements had a mean deviation of ± 3.02%.

METHODS

Chemotherapy doses prepared under a biological safety cabinet containing two weights from the precision scale between 15 December 2010 and 30 March 2011 were eligible for inclusion. Empty syringes attached to a closed-system transfer device were weighed prior to product manipulation. The product was then prepared using the syringe pull-back method (volumetric technique) and the same syringe containing drug was weighed (gravimetric method).

RESULTS

A total of 1156 compounded sterile products were eligible for the study. The mean percent volume difference of preparations included was -0.53% with a range of -64.9% to 94.22% for individual doses. Of the prepared doses, 71.7% were within ± 5% and 87.4% were within ± 10% of the ordered dose. Secondary outcomes found to be associated with an increased percent volume difference were the pediatric population, smaller volumes prepared, drugs requiring reconstitution compared to already in solution, and final product dispensed to the patient in syringes.

CONCLUSION

While the mean value of volumetric measurements is within the generally understood acceptable range for dispensing chemotherapy, the range of measurements is highly variable. Future studies are warranted to better understand the reasons behind the variation and to evaluate the impact of workflow changes on improving final product accuracy.

Estimated cost savings from reducing errors in the preparation of sterile doses of medications

BACKGROUND

Preventing intravenous (IV) preparation errors will improve patient safety and reduce costs by an unknown amount.

OBJECTIVE

To estimate the financial benefit of robotic preparation of sterile medication doses compared to traditional manual preparation techniques.

METHODS

A probability pathway model based on published rates of errors in the preparation of sterile doses of medications was developed. Literature reports of adverse events were used to project the array of medical outcomes that might result from these errors. These parameters were used as inputs to a customized simulation model that generated a distribution of possible outcomes, their probability, and associated costs.

RESULTS

By varying the important parameters across ranges found in published studies, the simulation model produced a range of outcomes for all likely possibilities. Thus it provided a reliable projection of the errors avoided and the cost savings of an automated sterile preparation technology. The average of 1,000 simulations resulted in the prevention of 5,420 medication errors and associated savings of $288,350 per year. The simulation results can be narrowed to specific scenarios by fixing model parameters that are known and allowing the unknown parameters to range across values found in previously published studies.

CONCLUSIONS

The use of a robotic device can reduce health care costs by preventing errors that can cause adverse drug events.

Does applying technology throughout the medication use process improve patient safety with antineoplastics?

PURPOSE

Medical errors, in particular medication errors, continue to be a troublesome factor in the delivery of safe and effective patient care. Antineoplastic agents represent a group of medications highly susceptible to medication errors due to their complex regimens and narrow therapeutic indices. As the majority of these medication errors are frequently associated with breakdowns in poorly defined systems, developing technologies and evolving workflows seem to be a logical approach to provide added safeguards against medication errors.

SUMMARY

This article will review both the pros and cons of today's technologies and their ability to simplify the medication use process, reduce medication errors, improve documentation, improve healthcare costs and increase provider efficiency as relates to the use of antineoplastic therapy throughout the medication use process. Several technologies, mainly computerized provider order entry (CPOE), barcode medication administration (BCMA), smart pumps, electronic medication administration record (eMAR), and telepharmacy, have been well described and proven to reduce medication errors, improve adherence to quality metrics, and/or improve healthcare costs in a broad scope of patients. The utilization of these technologies during antineoplastic therapy is weak at best and lacking for most. Specific to the antineoplastic medication use system, the only technology with data to adequately support a claim of reduced medication errors is CPOE. In addition to the benefits these technologies can provide, it is also important to recognize their potential to induce new types of errors and inefficiencies which can negatively impact patient care.

CONCLUSION

The utilization of technology reduces but does not eliminate the potential for error. The evidence base to support technology in preventing medication errors is limited in general but even more deficient in the realm of antineoplastic therapy. Though CPOE has the best evidence to support its use in the antineoplastic population, benefit from many other technologies may have to be inferred based on data from other patient populations. As health systems begin to widely adopt and implement new technologies it is important to critically assess their effectiveness in improving patient safety.

Efficacy versus safety concerns for aerosol chemotherapy in non-small-cell lung cancer: a future dilemma for micro-oncology

Inhaled chemotherapy was first used more than 30 years ago. Since then, numerous chemotherapeutic agents have been used in either in vitro or in vivo studies. Several aspects of the methodology of the drug administration have been thoroughly demonstrated and explained. However, the safety concerns of these studies were not thoroughly investigated and different results regarding the same drug formulations have been reported. There are cases where the studies failed to demonstrate the long-term effects of the chemotherapeutic drug formulations to the lung parenchyma. Acute and latent effects observed in a small number of human trial studies are still under investigation of inhaled chemotherapy administration. This review provides data regarding all up-to-date inhaled chemotherapy studies and presents the methodological parameters of the safety measures incorporated. In addition, a commentary regarding the safety concerns for the medical staff participating in these studies will be presented.