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

Evaluation of cancer drug infusion devices prior to the implementation of a compounding robot

INTRODUCTION

Compounding robots are increasingly being implemented in hospital pharmacies. In our hospital, the recent acquisition of a robot (RIVATM, ARxIUM) for intravenous cancer drug compounding obliged us to replace the previously used infusion devices. The objective of the present study was to assess and qualify the new intravenous sets prior to their use in our hospital and prior to the implementation of the compounding robot.

MATERIALS AND METHODS

The ChemoLockTM (ICU Medical) was compared with the devices used previously for compounding (BD PhaSealTM, Becton-Dickinson) and infusion (Connect-ZTM, Codan Medical). The connection/disconnection of infusion devices to/from 50 mL infusion bags was tested with a dynamometer (Multitest-i, Mecmesin). Leakage contamination was visualized by a methylene blue assay and was quantified in simulated pump infusions with 20 mg/mL quinine sulfate (N = 36/group); after the analytical assay had been validated, quinine was detected by UV-spectrophotometry at 280 and 330 nm. Groups were compared using chi-squared or Mann-Whitney U tests.

RESULTS

The connection/disconnection test showed that although all the devices complied with the current standard, there was a statistically significant difference in the mean ± standard deviation compression force (51.5 ± 11.6 for the Connect-ZTM vs. 60.3 ± 11.7 for the ChemoLockTM; p = 0.0005). Leaks were detected in 32 (29.1%) of the 110 tests of the ChemoLockTM. The contamination rates were also significantly different: 13.9% for the BD PhaSealTM versus 75.0% for the ChemoLockTM; p < 0.0001).

DISCUSSION/CONCLUSION

Our results showed that the new infusion device complied with current standards. However, the presence of contamination emphasizes the need for operators to use the recommended personal protective equipment. Further studies of contamination with cancer drugs are required.

Manual versus automated chemotherapy preparation: A retrospective pharmaco-economic analysis

INTRODUCTION

The National Oncology Institute of Morocco's (NIO) shift to an automated cytotoxic drug preparation system (PHARMODUCT®) has prompted an evaluation of its economic and clinical impacts compared to traditional manual methods.

METHODS

A retrospective cost-benefit analysis over six months, extrapolated to annual projections, assessed initial investments, labour, equipment, drugs and consumables. Four commonly used chemotherapy drugs were analyzed, with a focus on the cost implications of drug waste in manual preparation versus the efficiency of vial-sharing in automated methods.

RESULTS

The automated system incurred a higher initial cost $2,934,098.74, but reduced annual drug consumption costs by 19.74% and drug-related expenses by $41,228.27. It also decreased personnel costs by $48,073.35. Despite the upfront investment, the system is projected to break even within two years, with no medication waste due to its vial-sharing capability.

CONCLUSION

The initial higher investment in pharmaceutical automation promises considerable long-term savings and efficiency gains. Despite the study's limited scope and duration, the findings endorse the adoption of automated systems in oncology pharmacy settings for sustainable financial management and improved clinical outcomes.

Evaluation of oncology infusion pharmacy practices: A nationwide survey

PURPOSE

Oncology care continues to evolve at a rapid pace including provision of infusion-based care. There is currently a lack of robust metrics around oncology infusion centers and pharmacy practice. The workgroup completed a nationwide survey to learn about oncology-based infusion pharmacy services offered. The objective was to highlight consistent, measureable oncology-based infusion pharmacy metrics that will provide a foundation to describe overall productivity including emphasis on high patient-safety standards.

METHODS

A nationwide survey was developed via a workgroup within the Vizient Pharmacy Cancer Care Group beginning in April 2019 and conducted electronically via the Vizient Pharmacy Network from September to November 2020. The survey was designed to capture a number of key metrics related to oncology-based infusion pharmacy services.

RESULTS

Forty-one sites responded to the survey. Responses highlighted hours of operation (median = 11.5), number of infusion chairs (median = 45). Staffing metrics included 7.1 pharmacist full-time equivalent (FTE) and 7.6 technician FTE per week. 80.5% of sites had cleanrooms and 95.1% reported both hazardous and nonhazardous compounding hoods. 68.3% of sites reported using intravenous (IV) technology, 50.0% measured turnaround time, and 31.4% prepared treatment medications in advance.

CONCLUSION

There was variability among oncology infusion pharmacy practices in regard to survey responses among sites. The survey results highlight the need for standardization of established productivity metrics across oncology infusion pharmacies in order to improve efficiency and contain costs in the changing oncology landscape. The survey provides insight into oncology infusion pharmacy practices nationwide and provides information for pharmacy leaders to help guide their practices.

Deviations From Best Practice: Findings From a Certified Patient Safety Organization Remote-Verification Observational Study of Intravenous Compounding of Chemotherapeutic and Ancillary Drugs

Background: Chemotherapeutic and immunomodulatory medications can pose a serious risk to patient and healthcare provider safety because of complex processes, cytotoxicity, and prevalent medication use. Objective: To evaluate chemotherapeutic and ancillary medication compounding in hospital pharmacies using a remote verification system, focusing on pharmaceutical deviations from best practice, compounding time, medication waste, and cost. Methods: This retrospective, blinded observational study used a remote intravenous (IV) workflow verification system to examine IV chemotherapeutic compounding errors in large hospital systems. A Patient Safety Organization securely obtained >5000 compounding records and photos from the IV workflow system. Blinded pharmacists evaluated IV chemotherapy preparations using picture slide viewers to assess any deviations from best practice. Time variables, medication waste, STAT vs non-STAT orders, and cost were also evaluated. Results: The most frequently reported deviations from best practice included medications exceeding the >10% additive volume guideline (35.9%) and inaccurate dose labels (28.3%). Time flow analyses demonstrated a substantial increase in total compounding time per vial for 1 vs 2 vials. Most medications in this analysis had an average waste ranging from 0-.36 vials. STAT orders, accounting for 38.4% of all orders, wasted more medication than non-STAT orders. Gemcitabine cost analyses showed an association for number of vials and compounding time with overall cost per dose. Conclusion: Substantial inconsistencies between workflow stations were observed-highlighting the lack of standardization across chemotherapeutics, volume of medication waste during preparation, and the need to establish improved quality controls to safeguard patient and health care provider safety.

Comparing different robots available in the European market for the preparation of injectable chemotherapy and recommendations to users

INTRODUCTION

Recent advances in technology have made it possible to develop robots for preparing injectable anticancer drugs. This study aims to compare characteristics between robots available in the European market in 2022 and to help future pharmacy users in their choices.

METHODS

Three sources of data were used: (1) a review of published articles in the MEDLINE database from November 2017 to end of June 2021 on chemotherapy-compounding robots used in hospital; (2) all manufacturers' documentation, and (3) demonstrations of robot operations in real hospital conditions and discussions with users and manufacturers. Robot characteristics included number of robots installed, general technical characteristics, type of injectable chemotherapy produced and compatible materials, productivity data, preparation control methods, residual manual tasks, chemical and microbiological risk management, cleaning method, software, and implementation time.

RESULTS

Seven robots commercialized were studied. Several technical characteristics have to be taken into account in selecting the robot whose match the specific needs of a particular hospital, and which often require rethinking the current production workflow as well as the organization of the pharmacy unit. In addition to increasing productivity, the robots improve the quality of production thanks to better traceability, reproducibility, and precision of sampling. They also improve user protection against chemical risk, musculoskeletal disorders, and needle wounds. Nevertheless, when robotization is being planned, there are still numerous residual manual tasks to keep in mind.

CONCLUSION

Robotization of the production of injectable anticancer drugs is booming within anticancer chemotherapy preparation pharmacy units. Feedback from this experience needs to be further shared with the pharmacy community regarding this significant investment.

Contribution of an anticancer drug compounding robot in reducing the risks of manual preparation in a hospital pharmacy unit specialized in oncology

INTRODUCTION

In the last few years, pharmaceutical technology has evolved. In the field of oncology pharmacy, robots for the preparation of anti-cancer drugs have appeared to progressively replace manual preparation. The objective of this study is to evaluate the contribution of the robot in reducing the risk of manual preparation.

METHODS

The study was conducted at the pharmacy of the National Institute of Oncology in Rabat (May-August 2021). The method used to compare the two types of preparation is the method of analysis of failure modes, their effects and their criticality (FMECA). It will calculate the criticality index (CI = severity × frequency × detectability). The risks have been categorized into human, technical, and environmental risks.

RESULTS

The anticancer drugs reconstitution step was the most critical in manual preparation (CI = 126.7) and robotic preparation (CI = 40.7). The robot has made it possible to reduce several CIs of manual preparation including: musculoskeletal disorders of pharmacy operators -93 (89%), error in cancer drug and diluent selection -72 (60%), as well as lack of traceability -145 (97%).

CONCLUSION

The preparation robot has made it possible to reduce many of the risks of manual preparation, and constitutes an important advance in the field of oncology pharmacy.

Computer programs used in the field of hospital pharmacy for the management of dangerous drugs: systematic review of literature

Background

This review wants to highlight the importance of computer programs used to control the steps in the management of dangerous drugs. It must be taken into account that there are phases in the process of handling dangerous medicines in pharmacy services that pose a risk to the healthcare personnel who handle them. Objective: To review the scientific literature to determine what computer programs have been used in the field of hospital pharmacy for the management of dangerous drugs (HDs).

Methods

The following electronic databases were searched from inception to July 30, 2021: MEDLINE (via PubMed), Embase, Cochrane Library, Scopus, Web of Science, Latin American and Caribbean Literature in Health Sciences (LILACS) and Medicine in Spanish (MEDES). The following terms were used in the search strategy: "Antineoplastic Agents," "Cytostatic Agents," "Hazardous Substances," "Medical Informatics Applications," "Mobile Applications," "Software," "Software Design," and "Pharmacy Service, Hospital."

Results

A total of 104 studies were retrieved form the databases, and 18 additional studies were obtained by manually searching the reference lists of the included studies and by consulting experts. Once the inclusion and exclusion criteria were applied, 26 studies were ultimately included in this review. Most of the applications described in the included studies were used for the management of antineoplastic drugs. The most commonly controlled stage was electronic prescription; 18 studies and 7 interventions carried out in the preparation stage focused on evaluating the accuracy of chemotherapy preparations.

Conclusion

Antineoplastic electronic prescription software was the most widely implemented software at the hospital level. No software was found to control the entire HD process. Only one of the selected studies measured safety events in workers who handle HDs. Moreover, health personnel were found to be satisfied with the implementation of this type of technology for daily work with these medications. All studies reviewed herein considered patient safety as their final objective. However, none of the studies evaluated the risk of HD exposure among workers.

Intravenous compounding robots in pharmacy intravenous admixture services: A systematic review

BACKGROUND

There is a lack of best evidence of intravenous compounding robots for hospital decision-makers. This study aimed to conduct a systematic review of intravenous compounding robots.

METHODS

A comprehensive search of relevant professional health technology assessment websites and electronic databases was conducted from inception to February 3, 2022. Current studies related to intravenous compounding robots were included in this systematic review. Two reviewers independently screened the literature, extracted data, and assessed quality. The results were reported by qualitative description because of heterogeneity in the characteristics of the data in the included studies.

RESULTS

Thirty-three studies were included. Effectiveness: The robots improved production efficiency compared with usual/manual preparation; however, the intravenous preparation process requires further optimization. Additionally, robots reduced the incidence of medicine residues, preparation errors, and preparation failures. The solution properties of intravenous admixture medicines were satisfactory, and the robots also contributed to error recognition. Safety: The robots reduced product pollution and environmental pollution, but vigilance is still required to ensure that pollution stays low. The robots also reduced the incidence of health damage to technicians. Economy: The robots reduced material costs in these studies; however, whether they can reduce labor costs remains unclear. Social suitability: Technicians had a high degree of satisfaction with the robots, but few relevant studies focused on this aspect.

CONCLUSIONS

Intravenous compounding robots have certain advantages in terms of effectiveness, safety, economy, and social adaptability.

Evaluation of Robotic Systems on Cytotoxic Drug Preparation: A Systematic Review and Meta-Analysis

Background and Objectives: With the increased prevalence of patients with cancer, the demand for preparing cytotoxic drugs was increased by health-system pharmacists. To reduce the workload and contamination of work areas in pharmacies, compounding robots preparing cytotoxic drugs have been introduced, and the use of the robots has been expanded in recent years. As reports on the comprehensive and quantitative evaluation of compounding robots remain lacking, a systematic review and meta-analysis were conducted to provide descriptive and quantitative evaluations of the accuracy of preparing injectable cytotoxic drugs. Materials and Methods: A systematic review and meta-analysis were conducted using published studies up to 2020. To identify eligible studies, PubMed, EMBASE, and Cochrane Library were used. All studies reporting the outcomes relevant to drug-compounding robots such as accuracy, safety, and drug contamination were included. Outcomes from included studies were descriptively summarized. Drug contamination by the robot was quantitatively analyzed using the odds ratio (OR) with a 95% confidence interval (CI). The risk of bias was assessed using the Risk of Bias Assessment tool for Non-randomized Studies (RoBANS). Results: A total of 14 compounding robot studies were eligible for review and 4 studies were included in the meta-analysis. Robotic compounding showed failure rates of 0.9–16.75%, while the accuracy range was set at 5%. Two studies reported that robotic compounding needed more time than manual compounding, two reported that robotic compounding needed less time, and one just reported preparation time without a control group. In a meta-analysis regarding the contamination of the compounding area, manual compounding was associated with lower contamination, although the result was not statistically significant (OR 4.251, 95% CI 0.439–51.772). For the contamination of infusion bags, the robot was associated with lower contamination (OR 0.176, 95% CI 0.084–0.365). Conclusions: Robotic compounding showed better accuracy than manual compounding and, without control groups, showed a high accuracy rate and also reduced the risk of drug contamination and compounding workload. The preparation time of the robot was not consistent because the type of robot and introduced system were different. In conclusion, robotic compounding showed mixed results compared to the manual compounding of drugs, so the system should be introduced considering the risks and benefits of robots.

An Overview of the Current State and Perspectives of Pharmacy Robot and Medication Dispensing Technology

It has been widely reported that a large number of patients die from cases of errors in the issuing of medication prescriptions. These cases occur due to a wide range of things, but the common denominator in all of the cases is humans. A hospital pharmacy has a very critical task, especially with growing patient numbers. The increasing number of prescriptions needed to be filled daily reduces the amount of time that the staff can use to focus on each individual prescription, which may increase the human error ratio. The need for robotic-assisted pharmacies is arising from here to distribute drugs to eradicate or substantially reduce human error. The pharmacy robot is one of the most significant technologies that play a prominent role in the advancement of hospital pharmacy systems. The purpose of this review paper is to cover the pharmacy robot concept and the published literature reporting on pharmacy robot technology as one of the most important applications of artificial intelligence (AI) in pharmacology. Although the outcomes of the impact of the pharmacy robot have been increasingly beneficial in overall improvement, staff morale, and functionality of pharmacies, there are still mechanical errors occurring. The errors, in turn, require human intervention. The key takeaway from this study is that robots or machines cannot replace human duties in their entirety. This in turn means that those human interventions will have an impact on the workflow and throughput.

Nano- and Crystal Engineering Approaches in the Development of Therapeutic Agents for Neoplastic Diseases

Cancer is a leading cause of death worldwide. It is a global quandary that requires the administration of many different active pharmaceutical ingredients (APIs) with different characteristics. As is the case with many APIs, cancer treatments exhibit poor aqueous solubility which can lead to low drug absorption, increased doses, and subsequently poor bioavailability and the occurrence of more adverse events. Several strategies have been envisaged to overcome this drawback, specifically for the treatment of neoplastic diseases. These include crystal engineering, in which new crystal structures are formed to improve drug physicochemical properties, and/or nanoengineering in which the reduction in particle size of the pristine crystal results in much improved physicochemical properties. Co-crystals, which are supramolecular complexes that comprise of an API and a co-crystal former (CCF) held together by non-covalent interactions in crystal lattice, have been developed to improve the performance of some anti-cancer drugs. Similarly, nanosizing through the formation of nanocrystals and, in some cases, the use of both crystal and nanoengineering to obtain nano co-crystals (NCC) have been used to increase the solubility as well as overall performance of many anticancer drugs. The formulation process of both micron and sub-micron crystalline formulations for the treatment of cancers makes use of relatively simple techniques and minimal amounts of excipients aside from stabilizers and co-formers. The flexibility of these crystalline formulations with regards to routes of administration and ability to target neoplastic tissue makes them ideal strategies for effectiveness of cancer treatments. In this review, we describe the use of crystalline formulations for the treatment of various neoplastic diseases. In addition, this review attempts to highlight the gaps in the current translation of these potential treatments into authorized medicines for use in clinical practice.

Impact of technology-assisted versus manual sterile compounding on safety and efficiency in a Canadian community hospital

Purpose

Interventions to improve the safety and efficiency of manual sterile compounding are needed. This study evaluated the impact of a technology-assisted workflow system (TAWS) on sterile compounding safety (checks, traceability, and error detection), and efficiency (task time).

Methods

Observations were conducted in an oncology pharmacy transitioning from a manual to a TAWS process for sterile compounding. Process maps were generated to compare manual and TAWS checks and traceability. The numbers and types of errors detected were collected, and task times were observed directly or via TAWS data logs.

Results

Analysis of safety outcomes showed that, depending on preparation type, 3 to 4 product checks occurred in the manual process, compared to 6 to 10 checks with TAWS use. TAWS checks (barcoding and gravimetric verification) produced better traceability (documentation). The rate of incorrect-drug errors decreased with technology-assisted compounding (from 0.4% [5 of 1,350 preparations] with the manual process to 0% [0 of 1,565 preparations] with TAWS use; P < 0.02). The TAWS increased detection of (1) errors in the amount of drug withdrawn from vials (manual vs TAWS, 0.4% [5/1,350] vs 1.2% [18/1565]; P < 0.02), and (2) errors in the amount of drug injected into the final container (manual vs TAWS, 0% [0/1,236] vs 0.9% [11/1,272]; P < 0.002). With regard to efficiency outcomes, TAWS use increased the mean mixing time (manual vs TAWS, 275 seconds vs 355 seconds; P < 0.001), had no significant impact on average visual checking time (manual vs TAWS, 21.4 seconds vs 21.6 seconds), and decreased average physical checking time (manual vs TAWS, 58.6 seconds vs 50.9 seconds; P < 0.001).

Conclusion

In comparison to manual sterile compounding, use of the TAWS improved safety through more frequent and rigorous checks, improved traceability (via superior documentation), and enhanced error detection. Results related to efficiency were mixed.

Exposure to Antineoplastic Drugs in Occupational Settings: A Systematic Review of Biological Monitoring Data

The high toxicity of antineoplastic drugs (ADs) makes them dangerous not only for patients, but also for exposed workers. Therefore, the aim of this review was to provide an updated overview of the biological monitoring of occupational AD exposure in order to extrapolate information useful to improve risk assessment and management strategies in workplaces. Several studies demonstrated that remarkable portions of healthcare workers may have traces of these substances or their metabolites in biological fluids, although with some conflicting results. Nurses, directly engaged in AD handling, were the occupational category at higher risk of contamination, although, in some cases, personnel not involved in AD-related tasks also showed quantifiable internal doses. Overall, further research carried out on greater sample sizes appears necessary to gain deeper insight into the variability retrieved in the reported results. This may be important to understand the impact of the extent of ADs use, different handling, procedures, and cleaning practices, spill occurrence, training of the workforce, as well as the adoption of adequate collective and personal protective equipment in affecting the occupational exposure levels. This may support the achievement of the greatest clinical efficiency of such therapies while assuring the health and safety of involved workers.

Error Detection and Cost Savings With an Image-Based Workflow Management System Connected to a Computerized Prescription Order Entry Program for Antineoplastic Compounding

OBJECTIVE

The aim of the study was to analyze both the prevalence of errors with the implementation of an image-based workflow management system during the antineoplastic compounding process, and the estimated costs associated with the negative clinical outcome if the errors had not been intercepted.

METHODS

Three months after the implementation of Phocus Rx system at a hospital pharmacy department, the identification, classification (type, preparation stage, and cause), and potential severity degree (from negligible to catastrophic) of the errors intercepted were determined. The probability of an error causing an adverse event if it had reached the patient (from nil [0] to high [0.6]) and its consequences was estimated by a team of clinical pharmacists and physicians. Cost-effectiveness analysis from the hospital's perspective was performed.

RESULTS

Overall, 9872 antineoplastic medications were prepared using Phocus Rx. The total compounding error rate was 0.8% (n = 78, 56 [69.2%] were related to incorrect dose, 20 [28.2%] to incorrect drug preparation or conditioning technique, and 2 [2.6%] were wrong drugs). Approximately 70% of the detected errors were classified as undetectable via the previous verification practice, with 11.55% judged to be potentially severe (n = 9) and 51.3% moderate (n = 29). Likelihood of occurrence of an adverse event was medium (0.4) to high (0.6) for 37.2% of the errors. Estimated cost ratio and return on investment were €4.21 and 321%, respectively.

CONCLUSIONS

The implementation of Phocus Rx prevented antineoplastic preparation errors that would have reached the patient otherwise. In addition, acquisition of this technology was estimated to be cost-effective.

Preparations of exploration of immediate hypersensitivity to antineoplastic agents: An oncology pharmacy perspective

BACKGROUND

Cancer patients are being exposed to antineoplastic drugs more frequently and for longer periods, resulting in a higher risk of hypersensitivity reactions. The aim of this study was to assess the pharmaceutical time and direct cost of drug allergy explorations following immediate hypersensitivity reactions to antineoplastic agents.

METHODS

A micro-costing method was used to collect data on consumption of human and material resources for allergy exploration preparations. The monetisation was carried out on the basis of prices and hourly wage costs applied in 2018. The number and type of allergy explorations prepared by the pharmacy as well as nature of antineoplastic drugs tested, and the number of culprit drugs reintroductions were collected.

RESULTS

Almost 1.5 h is required to realise allergy tests for one patient including pharmacist time for prescription analysis and pharmacy technician's time for tests preparation. The mean manufacturing cost of these tests is estimated at €62.87 (€57.82-65.49) per culprit drug for one patient. Programming patients according to culprit drugs tested allows rationalising healthcare provider time and increasing efficiency. From January 2010 to December 2018, 277 patients were tested and 490 allergy explorations were performed, corresponding to more than 5000 preparations. Mostly, the culprit drug could be reintroduced (n = 383, 78.2%) allowing patients to receive the best possible treatment.

CONCLUSION

Management of hypersensitivity reactions is constantly progressing, as it contributes to improving patient care in oncology. This activity is time-consuming for the pharmacy team but allows patients with previous hypersensitivity reaction to continue effective treatment.

Prevalence and determinants of intravenous admixture preparation errors: A prospective observational study in a university hospital

Background Intravenous admixture preparation errors (IAPEs) may lead to patient harm. Insight into the prevalence as well as the determinants associated with these IAPEs is needed to elicit preventive measures. Aim The primary aim of this study was to assess the prevalence of IAPEs. Secondary aims were to identify the type, severity, and determinants of IAPEs. Method A prospective observational study was performed in a Dutch university hospital. IAPE data were collected by disguised observation. The primary outcome was the proportion of admixtures with one or more IAPEs. Descriptive statistics were used for the prevalence, type, and severity of IAPEs. Mixed-effects logistic regression analyses were used to estimate the determinants of IAPEs. Results A total of 533 IAPEs occurred in 367 of 614 admixtures (59.8%) prepared by nursing staff. The most prevalent errors were wrong preparation technique (n = 257) and wrong volume of infusion fluid (n = 107). Fifty-nine IAPEs (11.1%) were potentially harmful. The following variables were associated with IAPEs: multistep versus single-step preparations (adjusted odds ratio [OR_adj] 4.08, 95% confidence interval [CI] 2.27–7.35); interruption versus no interruption (OR_adj 2.32, CI 1.13–4.74); weekend versus weekdays (OR_adj 2.12, CI 1.14–3.95); time window 2 p.m.-6 p.m. versus 7 a.m.-10 a.m. (OR_adj 3.38, CI 1.60–7.15); and paediatric versus adult wards (OR_adj 0.14, CI 0.06–0.37). Conclusion IAPEs, including harmful IAPEs, occurred frequently. The determinants associated with IAPEs point to factors associated with preparation complexity and working conditions. Strategies to reduce the occurrence of IAPEs and therefore patient harm should target the identified determinants.

Robotic chemotherapy compounding: A multicenter productivity approach

INTRODUCTION

The aim of this study is to compare productivity of the KIRO Oncology compounding robot in three hospital pharmacy departments and identify the key factors to predict and optimize automatic compounding time.

METHODS

The study was conducted in three hospitals. Each hospital compounding workload and workflow were analyzed. Data from the robotic compounding cycles from August 2017 to July 2018 were retrospectively obtained. Nine cycle specific parameters and five productivity indicators were analysed in each site. One-to-one differences between hospitals were evaluated. Next, a correlation analysis between cycle specific factors and productivity indicators was conducted; the factors presenting a highest correlation to automatic compounding time were used to develop a multiple regression model (afterwards validated) to predict the automatic compounding time.

RESULTS

A total of 2795 cycles (16367 preparations) were analysed. Automatic compounding time showed a relevant positive correlation (ǀr_s|>0.40) with the number of preparations, number of vials and total volume per cycle. Therefore, these cycle specific parameters were chosen as independent variables for the mathematical model. Considering cycles lasting 40 minutes or less, predictability of the model was high for all three hospitals (R²:0.81; 0.79; 0.72).

CONCLUSION

Workflow differences have a remarkable incidence in the global productivity of the automated process. Total volume dosed for all preparations in a cycle is one of the variables with greater influence in automatic compounding time. Algorithms to predict automatic compounding time can be useful to help users in order to plan the cycles launched in KIRO Oncology.

Increasing pharmacy productivity and reducing medication turnaround times in an Italian comprehensive cancer center by implementing robotic chemotherapy drugs compounding

INTRODUCTION

The management of antineoplastic drugs used for chemotherapy is widely recognized as a high-risk activity. In 2018, our oncology pharmacy implemented workflow improvements to manage the growing workload due to the centralisation of activities from a hospital's satellite pharmacy, moving towards automated compounding of antineoplastic drugs.The aim of this study was to determine the impact of the centralization on the productivity of the pharmacy department and evaluate the performances of the robotic chemotherapy drugs compounding.

MATERIAL AND METHODS

Data were collected from the hospital information system and the workflow management software, and examined over a 3-year period (2017-2019). The total annual throughput in terms of doses prepared and patients treated and the Medication Turnaround Time (MTAT) were determined. Productivity and dosage accuracy were calculated for the robotic system.

RESULTS

In 2018, the number of patients treated increased by 16.6%, consequently, the overall number of intravenous preparations compounded in the pharmacy increased by 17.2%. Regarding manual compounding, the total number of antineoplastic preparations decreased by about 2%. Investigational treatments manually compounded increased by about 27%, in contrast to the non-investigational treatments, which decreased by 9.4%. Regarding robotic compounding, the annual production increased by 50.4%. In 2018, the MTAT decreased about 24%. The dosage accuracy and precision of the total amount of doses were -1.1% and 1.2%, respectively.

CONCLUSION

This study indicates that in the effort to satisfy an ever-increasing workload, computerization and automation are essential instruments to maintain and ensuring high standards of quality.

Comparison of IV oncology infusions compounded via robotics and gravimetrics-assisted workflow processes

Disclaimer

In an effort to expedite the publication of articles related to the COVID-19 pandemic, AJHP is posting these manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.

Purpose

A study was conducted to compare an intravenous (IV) gravimetric technology–assisted workflow (TAWF) platform to an IV robotic system. In the study we reviewed both IV technology platforms using the same gravimetric quality assurance system, which allowed for direct comparison.

Methods

All oncology preparations compounded from January 2016 through December 2018 using either system were included in our retrospective analysis. Final preparation accuracy, IV system precision, and workflow throughput (analyzed using lean process methodologies) were evaluated.

Results

Data analysis indicated that use of the IV gravimetric TAWF system was associated with a significantly lower percentage of accuracy errors compared to the IV robotics system (1.58% vs 2.47%, P < 0.001), with no significant difference in absolute precision (1.12 vs 1.12 P = 0.952). Lean analysis demonstrated that overall completion time (17:49 minutes vs 24:45 minutes) and compound preparation time (2:39 minutes vs 6:07 minutes) were less with the IV gravimetric TAWF vs the IV robotics system.

Conclusion

Implementation of either an IV gravimetric TAWF system or IV robotics system will result in similar compounding accuracy and precision. Preparation time was less with use of the IV gravimetric TAWF vs the IV robotic system, but the IV robotic system required less human intervention. Both systems ensure medication safety for patients, although the IV robotic system has increased safeguards in place. Therefore, the primary driver for implementing these systems is alternative factors such as cost of systems implementation and maintenance, employee safety, and drug waste.

Robotic compounding versus manual compounding of chemotherapy: Comparing dosing accuracy and precision

BACKGROUND

Cytostatic drugs are increasingly being prepared with a cytostatic robot, though it is not known whether the dose of the final product is more accurate after automated or manual preparation. This study is the first to compare accuracy and precision of automated preparations with manual preparations by measuring volumes and drug concentrations.

METHODS

The accuracy and precision of automated and manual preparations were compared by gravimetric and concentration measurements. During ten days 80 solutions were prepared; 40 robot preparations and 40 manual preparations. With both preparation methods, 20 methotrexate (MTX) and 20 cyclophosphamide (CP) bags were compounded. We simulated normal working conditions by performing the preparations on Monday till Friday. The MTX and CP concentrations were measured with validated ultra high performance liquid chromatography (UHPLC) methods on the last preparation day.

RESULTS

With UHPLC analysis, dose accuracy (mean dose error) of robotic or manual preparation of MTX were 1.70% and 0,96% respectively. With gravimetric analysis, these values were 0.50% and 1.96%. Precision (standard error) of the robotic preparation for MTX was significantly smaller than that of manual preparation (p < 0.001). Dose accuracy (mean dose error) of robotic or manual preparation of CP, with UHPLC analysis, were 6.10% and 5.20% respectively. With gravimetric analysis, these values were 0,67% and 0,18%.

CONCLUSION

We conclude that both robotic and manual compounding produce accurate cytostatic products in which the mean percentage of active substance differs by less than 10% from the prescribed amount. Both preparation methods are compliant with the Dutch Medicines Act and the European Pharmacopoeia.

Automated compounding technology and workflow solutions for the preparation of chemotherapy: a systematic review

OBJECTIVES

The current systematic review (SR) was undertaken to summarise the published literature reporting the clinical and economic value of automation for chemotherapy preparation management to include compounding workflow software and robotic compounding systems.

METHODS

Literature searches were conducted in MEDLINE, Embase and the Cochrane Library on 16 November 2017 to identify publications investigating chemotherapy compounding workflow software solutions used in a hospital pharmacy for the preparation of chemotherapy.

RESULTS

5175 publications were screened by title and abstract and 18 of 72 full publications screened were included. Grey literature searching identified an additional seven publications. The SR identified 25 publications relating to commercial technologies for compounding (Robotic compounding systems: APOTECAchemo (n=12), CytoCare (n=5) and RIVA (n=1); Workflow software: Cato (n=6) and Diana (n=1)). The studies demonstrate that compounding technologies improved accuracy in dose preparations and reduced dose errors compared with manual compounding. Comparable levels of contamination were reported for technologies compared with manual compounding. The compounding technologies were associated with reductions in annual costs compared with manual compounding, but the impact on compounding times was not consistent and was dependent on the type of compounding technology.

CONCLUSIONS

The published evidence suggests that the implementation of chemotherapy compounding automation solutions may reduce compounding errors and reduce costs; however, this is highly variable depending on the form of automation. In addition, the available evidence is heterogeneous, sparse and inconsistently reported. A key finding from the current SR is a 'call to action' to encourage pharmacists to publish data following implementation of chemotherapy compounding technologies in their hospital, which would allow for evidence-based recommendations on the benefits of chemotherapy compounding technologies.

Robotic Therapy: Cost, Accuracy, and Times. New Challenges in the Neonatal Intensive Care Unit

Background: The medication process in the Neonatal Intensive Care Unit (NICU), can be challenging in terms of costs, time, and the risk of errors. Newborns, especially if born preterm, are more vulnerable to medication errors than adults. Recently, robotic medication compounding has reportedly improved the safety and efficiency of the therapeutic process. In this study, we analyze the advantages of using the I.V. Station^® system in our NICU, compared to the manual preparation of injectable drugs in terms of accuracy, cost, and time. Method: An in vitro experimental controlled study was conducted to analyze 10 injectable powdered or liquid drugs. Accuracy was calculated within a 5% difference of the bottle weight during different stages of preparation (reconstitution, dilution, and final product). The overall cost of manual and automated preparations were calculated and compared. Descriptive statistics for each step of the process are presented as mean ± standard deviation or median (range). Results: The median error observed during reconstitution, dilution, and final therapy of the drugs prepared by the I.V. Station^® ranged within ±5% accuracy, with narrower ranges of error compared to those prepared manually. With increasing preparations, the I.V. Station^® consumed less materials, reduced costs, decreased preparation time, and optimized the medication process, unlike the manual method. In the 10 drugs analyzed, the time saved from using the I.V. Station^® ranged from 16 s for acyclovir to 2 h 57 min for teicoplanin, and cost savings varied from 8% for ampicillin to 66% for teicoplanin. These advantages are also capable of continually improving as the total amount of final product increases. Conclusions: The I.V. Station^® improved the therapeutic process in our NICU. The benefits included increased precision in drug preparation, improved safety, lowered cost, and saved time. These advantages are particularly important in areas such as the NICU, where the I.V. Station^® could improve the delivery of the high complexity of care and a large amount of intravenous therapy typically required. In addition, these benefits may lead to the reduction in medication errors and improve patient and family care; however, additional studies will be required to confirm this hypothesis.

Automated Compounding of Intravenous Therapy in European Countries: A Review in 2019

Automated compounding systems appeared on the market during these last 15 years as an alternative for manual compounding of intravenous (IVD) drugs. A literature review was conducted on reconstitution of IVD. The following methods were identified: manual, semi- automatic and automatic. A classification was carried out in three categories: automatic syringes, peristaltic pumps, and compounding doses robots. The number of compounding robots is increasing. A table describes the different features of each device. The ampuls cannot be supported by these robots. Large doses vials improve the time of reconstitution compared to current dosage vials. Advantages of automated preparation are: higher consistency of process and products, higher accuracy of products, Integrated digitized processing, precise, complete documentation, reduced effort and wrist injuries, reduced personnel requirement, increased worker satisfaction. Disadvantages of automated preparation are: risk of failure/down time, dependency on power supply, software (updates), high investment costs/high maintenance costs, specialized personnel with additional training, decreased worker satisfaction (early adopter), complexity when products are switched or added, potential for new errors. This review allows the potential user to know the current availability on the market.

Work overload is related to increased risk of error during chemotherapy preparation

PURPOSE

Chemotherapy preparation units face peaks in activity leading to high workloads and increased stress. The present study evaluated the impact of work overloads on the safety and accuracy of manual preparations.

METHOD

Simulating overwork, operators were asked to produce increasing numbers of syringes (8, 16, and 24), with markers (phenylephrine or lidocaine), within 1 h, in an isolator, under aseptic conditions. Results were analyzed using qualitative and quantitative criteria. Concentration deviations of < 5%, 5%-10%, 10%-30%, and >30% from the expected concentration were considered as accurate, weakly accurate, inaccurate, and wrong concentrations, respectively.

RESULTS

Twenty-one pharmacy technicians and pharmacists carried out 63 preparation sessions (n = 1007 syringes). A statistically significant decrease in the manufacturing time for one syringe was observed when workload increased (p < 0.0001). Thirty-nine preparation errors were recorded: 30 wrong concentrations (deviation > 30%), 6 mislabeling, 2 wrong diluents, and 1 wrong drug. There was no statistically significant difference in the mean concentration accuracy of final preparations across the three workloads. The overall error rate increased with the number of preparations made in 1 h: 1.8% for 8 preparations, 2.7% for 16 preparations, and 5.4% for 24 preparations (p < 0.05).

CONCLUSION

Although pharmacy technicians and pharmacists were able to increase production speeds with no effect on mean concentration accuracy under stressful conditions, there were greater probability errors being made. These results should encourage actions to spread workloads out over the day to avoid peaks in activity.

Automation of Aseptic Sterile Preparation: Risk Analysis and Productivity Comparison with Manual Process

Two automation methods for aseptic preparation in hospital pharmacy, robot and peristaltic pump, were compared to manual process both for risk analysis using Failure Modes Effects and Criticality Analysis (FMECA) method and for productivity using time analysis grids built for each process.

The results obtained with the different workflow organizations showed that the worst-case conditions for productivity was production “on demand” of tailor-made preparations. in that case, the manual process was not significantly different from the robotic process (p-value=0.72). For the standardized preparations, the semi-automatic process preparing a batch from bulk solution from “to be reconstituted” drugs was significantly superior to the robotic process preparing repetitive series of doses (p-value<0.01). Productivity of the robot was dramatically increased when the robot performed standardized preparations either from ready to use solutions or mixed cycles due to the robot design. When different processes were FMECA analyzed for risk analysis the robotic process was found as the safer process in comparison to others with a total of Criticality Indexes of 1060, 719, 656 for manual, semi-automatic and robot, respectively. Except for the robotic, semi-automatic and manual processes needed additional IT control systems to limit the risk of failures.

Efficiency of degradation or desorption methods in antineoplastic drug decontamination: A critical review

Although considerable efforts have been made over the last 40 years, occupational exposure to antineoplastic drugs is still a daily concern, since eradicating such contamination from workplaces seems unattainable. Considerable data are currently available on the risks associated with their use at work. Hospital facilities are often cleaned with marketed antimicrobials whose chemical decontamination efficacy certainly differs but remains unknown. To keep compounding facilities sterile, alcohol-based solutions are frequently used but with very limited efficiency. It would be particularly useful if a decontamination method could be added to the means already available so that all conventional antineoplastic drug contamination could be removed. Several degradation methods or desorption methods have previously been experimented, with varying success. They have never been compared or discussed in terms either of efficiency or usability. This review aims to analyse and discuss the results of each degradation or decontamination procedure and to compare them. This should facilitate selection of the method to be implemented in daily practice.

Simulation program of a cytotoxic compounding robot for monoclonal antibodies and anti-infectious sterile drug preparation

The aim of this study was to develop a specific simulation program for the validation of a cytotoxic compounding robot, KIRO® Oncology, for the preparation of sterile monoclonal antibodies and anti-infectious drugs. The impact of excipient formulations was clearly measured using simulation accuracy tests with worst case excipient (i.e. viscous, foaming) and allowed to correct the robotic settings prior to real production. Corrections brought accuracies within the acceptable range of ±5%. KIRO® Oncology robot has also the capacity of self-cleaning and a simulation combining media fill test, and environmental monitoring was able to validate the aseptic process including simulation of worst case conditions and highlighting the areas not accessible to self-cleaning to be corrected by additional manual cleaning measures. The risk of chemical contamination was simulated by using fluorescent dye of the process with high-risk excipient formulation and overpressure vials. Quality control reliability was simulated by using a model drug, and final concentration was determined by high-performance liquid chromatography-ultraviolet detection. Finally, productivity was simulated using different models of production showing the impact of the type of drug, the number of vials and the poor standardization of the process.

Qualification and Performance Evaluation of an Automated System for Compounding Injectable Cytotoxic Drugs

Background

Use of automated systems for the production of chemotherapy will increase in answer to hospitals’ needs to rationalise production. The aim of the study was to evaluate the performance of a PharmaHelp® automated system for compounding chemotherapy.

Methods

Viable and non viable particles in air and liquid were measured by particle counter. Surface chemical contamination was simulated with a quinine solution. Microbiological contamination and aseptic processes were studied using media-fill tests. Dose accuracy was evaluated using a gravimetric method, in simulation studies and with real products in daily practice. Productivity was calculated by batch of ten IV-bags.

Results

No particles or microbiological contamination were detected. Filling was accurate for all the volumes of non-viscous solution studied (97–103 %). Minimum volumes which could be prepared accurately were 2 mL and 5 mL for the non-viscous and viscous solutions, respectively. For 2–5 mL volumes, the robot was less accurate than average, and 0–2 % of bags were rejected (deviation>10 %). Average fill deviations were from 0–3 % for 2–5 mL volumes and<1 % for volumes above 5 mL. Average production time for ten bags was 61±11 min.

Conclusions

The automated system was able to produce chemotherapy effectively, delivering appropriate quality with productivity comparable to manual preparations. These results confirmed that such automated systems have the potential to guarantee optimal safety for patients and technicians.

Environmental and Product Contamination during the Preparation of Antineoplastic Drugs with Robotic Systems

Background

Robotic systems are designed to minimize the exposure to antineoplastic drugs during automated preparation. However, contamination cannot be completely excluded. The aim of the study was to evaluate the contamination with antineoplastic drugs on the working surfaces and on the outer surface of the ready-to-use products (infusion bags and syringes) during automated preparation with different versions of a robot and manual preparation.

Methods

Surface contamination with platinum (Pt) and 5-fluorouracil (5-FU) was measured by wipe sampling and quantified by voltammetry for Pt and GC-MS for 5-FU. Sampling was performed on pre-defined locations in the working areas before and after preparation of standardized test products. The outer surfaces of Pt- or 5-FU-containing infusion bags and 5-FU-containing syringes were sampled without and after manual capping.

Results

Overall, the surface contamination in the working areas of the robotic system ranged from 0.4 to 114 pg/cm2 for Pt and from 1.3 to 1,250,000 pg/cm2 for 5-FU. The highest contamination levels were detected after preparation on the gripper of the robotic arm and on the surface beneath the dosing device. In most cases, measured concentrations were higher after preparation. Outer surfaces of infusion bags prepared with the robotic system were less contaminated than manually prepared bags. Contamination on the outer surface of syringes varied depending on the procedure adopted.

Conclusions

The risk of contamination is localised inside the working area of the robot. The outer surfaces of products were only marginally contaminated. Cleaning procedures of the working area are to be further investigated. An effective decontamination procedure for the working area of the robot and automated capping of filled syringes should be developed to further minimize the occupational risk.

Implementation and evaluation of a sterile compounding robot in a satellite oncology pharmacy

PURPOSE

The purpose of this study was to quantify the impact of robotic technology on efficiency, accuracy, and cost in a satellite oncology pharmacy.

METHODS

A 33-week quasi-experimental study was conducted at an academic, quaternary care institution with 1,119 licensed beds from June 2016 to February 2017 to evaluate the turnaround time (TAT) for preparations compounded by automated robotic compounding technology (ARCT) versus historical procedures. Secondary endpoints included mean preparation time and percentage of doses with a TAT of <30 minutes before and after the implementation of ARCT and were evaluated using time-segmented regression analysis. The cost savings in the satellite oncology pharmacy was determined by comparing usage of closed-system transfer devices (CSTDs) and labor costs between study phases. Accuracy of the intervention was expressed through a descriptive analysis of mean ARCT dose preparation deviations and preparation failures.

RESULTS

Data for 1,453 preparations were included for analysis. The mean ± S.D. preimplementation TAT was 64.1 ± 27.9 minutes, which decreased to 53.2 ± 32.2 minutes after ARCT implementation (p < 0.01). Financial benefit was demonstrated through supply cost savings. Breakeven was estimated at 8.6 years after capital expenditure, with an annualized projected savings of $129,477. The mean ± S.D. deviation of the doses compounded using ARCT was -0.58% ± 0.01% from the ordered dosage.

CONCLUSION

Adoption of ARCT for compounding of admixtures containing 4 oncology agents reduced TAT and preparation time and led to lower expenditures for CSTDs.

Systematic evidence review of rates and burden of harm of intravenous admixture drug preparation errors in healthcare settings

OBJECTIVE

To examine published evidence on intravenous admixture preparation errors (IAPEs) in healthcare settings.

METHODS

Searches were conducted in three electronic databases (January 2005 to April 2017). Publications reporting rates of IAPEs and error types were reviewed and categorised into the following groups: component errors, dose/calculation errors, aseptic technique errors and composite errors. The methodological rigour of each study was assessed using the Hawker method.

RESULTS

Of the 34 articles that met inclusion criteria, 28 reported the site of IAPEs: central pharmacies (n=8), nursing wards (n=14), both settings (n=4) and other sites (n=3). Using the Hawker criteria, 14% of the articles were of good quality, 74% were of fair quality and 12% were of poor quality. Error types and reported rates varied substantially, including wrong drug (~0% to 4.7%), wrong diluent solution (0% to 49.0%), wrong label (0% to 99.0%), wrong dose (0% to 32.6%), wrong concentration (0.3% to 88.6%), wrong diluent volume (0.06% to 49.0%) and inadequate aseptic technique (0% to 92.7%)%). Four studies directly compared incidence by preparation site and/or method, finding error incidence to be lower for doses prepared within a central pharmacy versus the nursing ward and lower for automated preparation versus manual preparation. Although eight studies (24%) reported ≥1 errors with the potential to cause patient harm, no study directly linked IAPE occurrences to specific adverse patient outcomes.

CONCLUSIONS

The available data suggest a need to continue to optimise the intravenous preparation process, focus on improving preparation workflow, design and implement preventive strategies, train staff on optimal admixture protocols and implement standardisation. Future research should focus on the development of consistent error subtype definitions, standardised reporting methodology and reliable, reproducible methods to track and link risk factors with the burden of harm associated with these errors.

Parenteral product error detection before and after implementation of intravenous workflow management technology

Objective

To assess the difference in pharmacy error detection rates when using a manual process compared to an intravenous workflow management system for the preparation of parenteral medications.

Methods

Baseline error data were collected by staff using a standard form over a four-day time period before intravenous workflow management system implementation and compared to 48 weeks of electronically collected data following implementation. The chi-square test was used for statistical comparisons.

Results

The ability to detect an error during the intravenous preparation process increased immediately following implementation, but this difference was not sustained and was not statistically different when the entire post-implementation time period was compared to the baseline sample. The most prevalent errors at baseline were wrong drug amount (36.4%) and wrong base solution (22.7%). Post-implementation product expiration (26.1%), wrong diluent or base (17.9%), and wrong drug amount (19.2%) were the most prevalent errors. Barcode scanning technology detected 60% of the errors during the post-implementation period. A decrease in error detection over time was observed post-implementation and was attributed to corrections and additions to the intravenous workflow management library and better prospective identification of potential errors by staff as they adjusted to the system. The use of serial imaging enabled pharmacists to detect errors prospectively, which may have previously been undetected using the traditional intravenous preparation process.

Conclusion

The implementation of intravenous workflow management technology was unable to detect a statistically significant greater percentage of sterile product preparation errors compared with the baseline time period. Statistical significance was achieved during three of the first four months following implementation ( P < 0.05); however, this statistically significant increase was not maintained when the entire post-implementation sample was included.

Risk management of onco-hematological drugs: how and how fast can we improve?

PURPOSE

Medication errors in oncology may cause severe damage to patients, professionals, and the environment. The Italian Ministry of Health issued Raccomandazione 14 to provide guidelines for prevention of errors while using antineoplastic drugs. This work aimed at analyzing Raccomandazione 14 through the different viewpoints of the hospital pharmacist, the nurse, the oncologist, and the hospital director.

METHODS

Twenty-seven Italian healthcare organizations participated in a self-assessment survey evaluating compliance with Raccomandazione 14 within the oncology, hematology, and pharmacy departments.

RESULTS

The self-assessment results showed a general acknowledgement of the need for centralized management of anticancer agents. The specific responsibility of the pharmacist on the centralized management of anticancer drugs from preparation to disposal emerged as a critical point. The nurse, beyond the skills in drug administration and prevention of extravasation, also plays a fundamental role in educating and supporting the patient. The physicians, who are attentive to scientific, clinical, and regulatory criteria in prescribing and monitoring the therapies, are called upon to improve awareness on the importance of sharing standardized procedures with other professionals, to minimize medication error occurrence. The implementation of a complete computerized management from prescribing to drug administration and follow-up was highlighted. Multidisciplinary groups were constituted across the nation by professionals dedicated to the implementation of electronic health records and drug history and medical reconciliation processes.

CONCLUSIONS

Our analysis of the Ministerial Raccomandazione 14 urges implementation of the resources for ensuring quality and safety during prescription, preparation, and administration of anticancer drugs.

Reliability of chemotherapy preparation processes: Evaluating independent double-checking and computer-assisted gravimetric control

Background and objectives Centralized chemotherapy preparation units have established systematic strategies to avoid errors. Our work aimed to evaluate the accuracy of manual preparations associated with different control methods. Method A simulation study in an operational setting used phenylephrine and lidocaine as markers. Each operator prepared syringes that were controlled using a different method during each of three sessions (no control, visual double-checking, and gravimetric control). Eight reconstitutions and dilutions were prepared in each session, with variable doses and volumes, using different concentrations of stock solutions. Results were analyzed according to qualitative (choice of stock solution) and quantitative criteria (accurate, <5% deviation from the target concentration; weakly accurate, 5%-10%; inaccurate, 10%-30%; wrong, >30% deviation). Results Eleven operators carried out 19 sessions. No final preparation (n = 438) contained a wrong drug. The protocol involving no control failed to detect 1 of 3 dose errors made and double-checking failed to detect 3 of 7 dose errors. The gravimetric control method detected all 5 out of 5 dose errors. The accuracy of the doses measured was equivalent across the control methods ( p = 0.63 Kruskal-Wallis). The final preparations ranged from 58% to 60% accurate, 25% to 27% weakly accurate, 14% to 17% inaccurate and 0.9% wrong. A high variability was observed between operators. Discussion Gravimetric control was the only method able to detect all dose errors, but it did not improve dose accuracy. A dose accuracy with <5% deviation cannot always be guaranteed using manual production. Automation should be considered in the future.

A three-year study of a first-generation chemotherapy-compounding robot

PURPOSE

Results of a performance evaluation of an automated system for compounding antineoplastic preparations are reported.

METHODS

Three years after the pharmacy department of a hospital in Saudi Arabia installed an i.v.-compounding robot (CytoCare, Health Robotics), data captured by the pharmacy information system and the machine's integrated software were analyzed to assess the performance of the robot in terms of compounding accuracy, days of operation, and downtime.

RESULTS

The robot was used to prepare 3.82%, 10.80%, and 13.79% of selected antineoplastics compounded in 2010, 2011, and 2012, respectively. The robot failed to meet the specified dose accuracy range of ±5% in compounding 3 of 337 chemotherapy preparations (0.9%) in 2010, 349 of 1516 preparations (23%) in 2011, and 460 of 2993 preparations (15%) in 2012. The robot was operational on 40%, 39%, and 61% of available workdays in 2010, 2011, and 2012, respectively. Robot throughput relative to the pharmacy's manual compounding process was low, with substantial medication waste resulting from dose preparation failures. Implementation challenges included workflow disruptions due to robot downtime, mechanical issues (e.g., robot arm-clamping failures), difficulty obtaining gravimetric data for some drugs, and the need to recalibrate the device to accept i.v. bags, syringes, and medication vials incompatible with manufacturer specifications.

CONCLUSION

The introduction of a chemotherapy-compounding robot for preparation of patient-specific i.v. antineoplastic drugs had a limited efficiency impact in practice. This solution, with its numerous limitations and technical difficulties, is not yet mature enough for universal adoption.

DrugCam®-An intelligent video camera system to make safe cytotoxic drug preparations

DrugCam(®) is a new approach to control the chemotherapy preparations with an intelligent video system that enables automatic verification during the critical stages of preparations combined with an a posteriori control with partial or total visualization of the video recording of preparations. The assessment was about the recognizing of anticancer drug vials (qualitative analysis) and syringe volumes (quantitative analysis). The qualitative analysis was conducted for a total of 120 vials with sensitivity of 100% for 84.2% of the vials and at least 97% for all the vials tested. Accuracy was at least 98.5% for all vials. The quantitative analysis was assessed by detecting 10 measures of each graduation for syringes. The identification error rate was 2.1% (244/11,640) i.e. almost 94% to the next graduation. Only 3% (35/1164) of the graduations tested, i.e. 23/35 for volume <0.13 ml of 1 ml syringes, presented a volume error outside the admissible limit of ± 5% of a confidence band constructed for the estimated linear regression line for each syringe. In addition to the vial detection model, barcodes can also read when they are present on vials. DrugCam(®) offers an innovative approach for controlling chemotherapy preparations and constitutes an optimized application of telepharmacy.

Aiming for ideal care: a proposed framework for cancer quality improvement

The authors review the advances made in oncology over the past 50 years and describe methods for closing the gap in care quality.

Reproductive health risks associated with occupational exposures to antineoplastic drugs in health care settings: a review of the evidence

OBJECTIVES

Antineoplastic drugs are known reproductive and developmental toxicants. Our objective was to review the existing literature of reproductive health risks to workers who handle antineoplastic drugs.

METHODS

A structured literature review of 18 peer-reviewed, English language publications of occupational exposure and reproductive outcomes was performed.

RESULTS

Although effect sizes varied with study size and population, occupational exposure to antineoplastic drugs seems to raise the risk of both congenital malformations and miscarriage. Studies of infertility and time to pregnancy also suggested an increased risk for subfertility.

CONCLUSIONS

Antineoplastic drugs are highly toxic in patients receiving treatment, and adverse reproductive effects have been well documented in these patients. Health care workers with long-term, low-level occupational exposure to these drugs also seem to have an increased risk of adverse reproductive outcomes. Additional precautions to prevent exposure should be considered.

A safe practice standard for barcode technology

OBJECTIVE

Safety advocates have identified barcode verification technology as an important tool to improve health-care practices.

METHODS

We evaluated the evidence for the role of barcode technology in improving a wide range of medication safety outcomes across a broad range of settings. Important implementation issues were highlighted to guide standards for the safe adoption of barcode technology.

RESULTS

Adverse drug events are common, occurring frequently in both inpatient and outpatient settings. Although approximately half of all preventable adverse drug events in inpatients result from medication errors arising from transcription, dispensing, and administration, these errors are far less likely to be caught than in any of the earlier stages of the medication use process and are therefore most amenable to improvement. When integrated with electronic medication administration records, barcode systems are associated with complete elimination of transcription errors. Furthermore, barcode-assisted dispensing systems are associated with 93% to 96% reductions in dispensing errors, and 85% reductions in potential adverse drug events in dispensing. Most studies have reported large and significant reductions in administration errors by up to 80% after implementation of barcode medication administration systems. Although most studies of barcode technology have been conducted in the adult inpatient setting, the limited data available also support their benefit in pediatric and outpatient settings.

CONCLUSIONS

There is growing evidence for the efficacy of barcode solutions in improving overall medication safety. Standards for the implementation of barcode technology are proposed.

Oncology pharmacy units: a safety policy for handling hazardous drugs and related waste in low- and middle-income African countries-Angolan experience

In African countries, higher rates of late-stage cancers at the time of first diagnosis are a reality. In this context, hazardous drugs (HDs), such as chemotherapy, play an important role and have immense benefits for patients' treatment. HDs should be handled under specific conditions. At least a class 5 environment primary engineering control (PEC), physically located in an appropriate buffer area, is mandatory for sterile HDs compounding, as well as administrative control, personal protective equipment, work practices and other engineering and environmental controls, in order to protect the environment, patient, and worker. The aim of this study is to describe the Angolan experience regarding the development of oncology pharmacy units and discuss international evidence-based guidelines on handling HDs and related waste. Measures to incorporate modern and economical solutions to upgrade or build adequate and safe facilities and staff training, in order to comply with international guidelines in this area, are crucial tasks for African countries of low and middle income.

Semiautomated aseptic preparation of patient-individual antineoplastic intravenous solutions: first experiences in a German hospital pharmacy

Objectives

In 2013, the PharmaHelp device was introduced to daily patient care at the University Hospital of Heidelberg in order to improve process and staff safety and health. It is a semiautomated device located in a safety workbench for aseptic preparation with weight-and-visual-supported process check as well as radio-frequency identification of bags and vials.

Methods

After qualification and a training period, several high-admixture-volume drugs were chosen stepwise to be prepared by the device. During a reporting period of 6 months, the number of processed production runs and produced bags were assessed as well as the productivity per hour of the device based on the processed admixing volume and time consumption for manual preprocessing and postprocessing steps.

Results

Weight conformity tests of 246 processed bags in 11 admixing-volume ranges showed 99.19% with a deviation of <5%. Validation of the automated preparation process with 40 media fills showed no microbiological growth. Daily patient care production in the first 6 months led to a nearly similar weight accuracy and an average productivity of 22.5 preparations per running hour of the device at an average admixing volume of 39.6 mL, excluding manual preprocessing and postprocessing tasks. Time consumption for all manual steps was about 76 min per run.

Conclusions

The automated admixing process of the device showed remarkable effectivity and a satisfying accuracy, but the manual preprocessing and postprocessing steps are time consuming, which is associated with the local environment, and has to be reorganised.

Safe handling of cytotoxics: guideline recommendations

BACKGROUND

This evidence-based practice guideline was developed to update and address new issues in the handling of cytotoxics, including the use of oral cytotoxics; the selection and use of personal protective equipment; and treatment in diverse settings, including the home setting.

METHODS

The guideline was developed primarily from an adaptation and endorsement of an existing guideline and from three systematic reviews. Before publication, the guideline underwent a series of peer and external reviews to gather feedback. All comments were addressed, and the guideline was amended when required. The guideline applies to health care workers who could come into contact with cytotoxic drugs at any point in the medication circuit. The intended users are hospital administrators, educators, and managers; occupational health and safety services; and pharmacy and health care workers.

RESULTS

The recommendations represent a reasonable and practical set of procedures that the intended users of this guideline should implement to minimize opportunities for accidental exposure. They are not limited to just the point of care; they cover the entire chain of cytotoxics handling from the time such agents enter the institution until they leave in the patient or as waste.

CONCLUSIONS

Reducing the likelihood of accidental exposure to cytotoxic agents within the medication circuit is the main objective of this evidenced-based guideline. The recommendations differ slightly from earlier guidelines because of the availability of new evidence.

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.