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

Analysis of production time and capacity for manual and robotic compounding scenarios for parenteral hazardous drugs

BACKGROUND

The increasing amount of hazardous preparations in combination with shortages leads to a call for more efficient compounding methods. This research aims to evaluate the required amount of time, production capacity and direct labour costs of the manual, manual software-supported and robotic compounding of parenteral hazardous drugs.

METHODS

This multicentre study was conducted at the clinical pharmacy departments of three Dutch hospitals with different compounding methods: St Antonius hospital (manual software-supported compounding), Amsterdam University Medical Centre (Amsterdam UMC) (both robotic compounding and manual compounding without software support) and OLVG (robotic compounding). Time measurements of individual hazardous drugs were performed in all three hospitals. At Amsterdam UMC and St Antonius hospital, the times per compounding phase, the production capacity and the direct labour costs per preparation were also determined. To reflect real-world situations, the combination of robotic and manual compounding was also studied.

RESULTS

The total compounding process, including the actions before compounding and the release-time and cleaning time, lasted 6:44 min with robotic compounding and was faster than manual compounding with and without software support (6:48 and 9:48 min, respectively). The production capacity of one full-time equivalent (FTE) on 1 day (P1FTE1day) was 15 preparations per FTE per day with manual compounding with and without software support, and 57 preparations per FTE per day with only robotic compounding. If manual and robotic compounding were combined, the production capacity was 30 preparations per FTE per day. In this setting, the direct labour costs per preparation were €5.21, while these costs were €13.18 with only manual compounding.

CONCLUSION

Compared with manual compounding, robotic compounding was faster over the total compounding process. A combination of manual compounding and robotic compounding could lead to 100% more preparations per FTE and 2.5 times lower direct labour costs compared with manual compounding.

Evaluation of the risk of occupational exposure to antineoplastic drugs in healthcare sector: part II - the application of the FMECA method to compare manual vs automated preparation

Healthcare workers handling antineoplastic drugs (ADs) in preparation units run the risk of occupational exposure to contaminated surfaces and associated mutagenic, teratogenic, and oncogenic effects of those drugs. To minimise this risk, automated compounding systems, mainly robots, have been replacing manual preparation of intravenous drugs for the last 20 years now, and their number is on the rise. To evaluate contamination risk and the quality of the working environment for healthcare workers preparing ADs, we applied the Failure Mode Effects and Criticality Analysis (FMECA) method to compare the acceptable risk level (ARL), based on the risk priority number (RPN) calculated from five identified failure modes, with the measured risk level (MRL). The model has shown higher risk of exposure with powdered ADs and containers not protected by external plastic shrink film, but we found no clear difference in contamination risk between manual and automated preparation. This approach could be useful to assess and prevent the risk of occupational exposure for healthcare workers coming from residual cytotoxic contamination both for current handling procedures and the newly designed ones. At the same time, contamination monitoring data can be used to keep track of the quality of working conditions by comparing the observed risk profiles with the proposed ARL. Our study has shown that automated preparation may have an upper hand in terms of safety but still leaves room for improvement, at least in our four hospitals.

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.

Process performance of a new liquid medication dispensing robot

OBJECTIVES

Liquid medications provide an alternative to splitting pills and dosages by measuring an amount of liquid rather than crushing tablets or opening capsules. Special attention should also be paid to specific patient groups with swallowing difficulties or requiring enteral feeding administration. Liquid medicines are also often used to ease withdrawal symptoms for people suffering from addiction. Nevertheless, filling liquid medication cups with the right medication and precise doses may be difficult for healthcare professionals. The Nooddis ('Nominative Oral Dose Dispenser'-Pierre Lôo Hospital, France and Packinov, France) is a new robotic system for the automated filling of single dose liquid medications. Since the performance of such a complex piece of equipment depends on compliance of the service provider to our building guidelines, the process performance verification is a necessary prerequisite before starting routine production.

METHODS

The performance of the Nooddis robot (accuracy, precision, and tapering calculation) and its ability to fill medicine cups was evaluated with 18 different liquid medications using an automatic in-line checkweigher. Microbiological testing was also performed.

RESULTS

648 sealed cups were prepared for qualification. The filling accuracy was within the limit of ±10% from 75 µL to 21.25 mL. The repeatability (% relative SD (%RSD) 0.05 to 4.93) and intermediate precision (%RSD 0.01 to 6.59) were validated for all preparations. All medicine cups met the requirements of USP and European Pharmacopoeia acceptance criteria for microbiological quality. Automated tapering calculations allowed for easy production of daily doses for the tapering periods chosen.

CONCLUSION

Since the system met the required quality standards, the Nooddis robot, with automatic in-line tapering system, is regarded as an accurate technology that can fill the exact amount of liquid oral medication in single dose cups. This may promote closer monitoring, which supports medication tapering as well as medication misuse prevention. With a packaging cost similar to current unit dose cup systems, it is a relevant alternative to fractioned or crushed tablets, as well as opened capsules. Further developments for some sterile liquid medications are yet to be studied.

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.

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.

[Robotic production of injectable anticancer drugs in hospital pharmacies]

INTRODUCTION

Following the 2005 decree on securing the medicine supply chain, the production of "chemotherapies", anticancer drugs (cytotoxic, cytostatic, immunotherapy), was centralised within hospital pharmacies. To cope with increasingly growing activities, pharmacies are moving towards robotisation. This work offers feedback from four French sites pioneers in robotic production.

MATERIAL AND METHOD

A review of the literature was carried out on the PubMed and Google Scholar scientific databases and GERPAC publications relating to the robotic production of chemotherapy preparations. This review allowed to select 25 articles.

RESULTS

The robotisation of the production of "chemotherapies" requires infrastructural prerequisites, a reengineering of the manufacturing process and the patient journey. This impacts all the parties involved in this complex process. The "cobotisation" concept or collaborative robotics must be anticipated by the teams. Robotisation is an institutional decision, which must be owned by the pharmaceutical team and endorsed by the medical team and management.

DISCUSSION/CONCLUSION

For reasons of optimisation, safeguarding and management of human resources, a large number of centres get equipped with robotic systems. Robotic preparation should extend to other non-hazardous preparation, as it is already the case in other countries. This strategic view should be carried out today to anticipate problems, ensure safety and improve the healthcare quality.

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.

Cleveland Clinic International IV Robotics Summit

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

The proceedings of an international summit on the current and desired future state of use of robotic systems to compound intravenous (IV) solutions are summarized.

Summary

The International IV Robotics Summit was held at the Cleveland Clinic main campus in Cleveland, OH, on April 29 and 30, 2019. The purpose of the summit was 2-fold: (1) to define the current state of robotic IV compounding and (2) to develop a guide for automation companies, pharmacy departments, and drug manufacturers to improve the technology and expand the use of IV robotics in health systems in the future. The first day of the summit included 45-minute presentations by each of the speakers. Each lecturer recounted a different hospital’s experience implementing and using IV robotics. On day 2 of the summit, an expert panel dedicated to mapping the future of IV robotics was convened to determine barriers to widespread adoption of IV robotics in health systems and offer potential solutions to remove these barriers. The expert panel targeted 3 specific audiences: robot manufacturers, drug manufacturers, and fellow pharmacy leaders.

Conclusion

It is the hope of the international faculty that the information that emerged from the summit can be used by others to successfully implement IV compounding robotics in their sterile products areas to maximize patient safety. The summit also served as a call to action for pharmacy leaders, drug manufacturers, and robotic companies to develop a safer, more efficient future for patients by working together to optimize the development and operation of IV robotics.

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.

Real-World Experience of a Standalone Robotic Device for Batch Compounding of Small-Volume Parenteral Preparations

Purpose: Intravenous (IV) drugs prepared by a robotic device offer additional safeguards and advantages, which result in decreased errors and wastage, operational efficiency, and a retrievable electronic audit trail when compared with the traditional method of IV drug compounding. Objectives: To describe the real-world experience of using Robotic IV Automation (RIVA; ARxIUM) from its implementation phase (August-December 2014) through to its operational phase (March 2015-March 2018) for batch compounding of small-volume preparations. Method: The Data Warehouse and Analytics were used extensively to generate reports for batch-prepared small-volume preparations from the implementation phase (August 2014-December 2014) through to the operational phase (March 2015-March 2018). These reports analyzed cleaning history, doses produced by drug and size, waiting times, daily usage and the rejection rate data of RIVA. A self-administered structured questionnaire with open-ended and closed questions was administered to the experienced stakeholders on the performance of RIVA after the evaluation period. The response scales used anchors such as 1 = strongly disagree to 5 = strongly agree. The questionnaire contained a 5-point Likert scale of 16 domains, including demographic data. Results: The number of sterile products prepared by the robot averaged about 5000 per month when it was fully operational (March 2015-April 2018). The highest number of daily preparations was 335 with an average of 262 during our evaluation period; this involved 21 production queues and a run time of 17:42 h/d and an average of 16:33 h/d/wk. We were able to operate the robot at about 45% of its true capacity; this enabled us to prepare a minimum of 30% of the small-volume parenteral preparations required at the time. Responses from the closed questions resulted in the agreeance that the overall impression of RIVA was “very good.” The safety features of RIVA had a median score of being “very safe.” The real impact of the automation was felt during the downtime of the IV robot; at this point, staff could evaluate the impact the robot had on the work flow within the IV room. Conclusions: This study demonstrated that it is feasible to replace some of the manual compounding of small-volume parenteral preparations through batch compounding using an IV robotic device. Despite operating the robot at about 45% of its true capacity, we prepared a minimum of 30% of our high-load small-volume parenteral preparations, which was our goal. Having proactive inventory planning would maximize the use of the IV robot and reduce the idle time, thus enabling the robot to function to its maximum potential and increase its efficiency.

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.

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.

Microbiological validation of a robot for the sterile compounding of injectable non-hazardous medications in a hospital environment

Objectives

To design and execute a comprehensive microbiological validation protocol to assess a brand-new sterile compounding robot in a hospital pharmacy environment, according to ISO and EU GMP standards.

Methods

Qualification of the Class-A inner environment of the robot was performed through microbial air and surface quality assessment utilising contact plates, swabs and particulate matter monitoring. To evaluate the effectiveness of the microbial decontamination process (UV rays) challenge test against Pseudomonas aeruginosa, Staphylococcus aureus, Bacillus subtilis spores and Candida albicans was used. The challenge Media Fill test was used to validate the aseptic processing.

Results

After 3 hours, no microorganisms retained viability. Monitoring inside the equipment evidenced complete absence of microorganisms. The Media Fill test was always negative.

Conclusions

According to our results, the APOTECAunit meets the requirements for advanced aseptic processing in the hospital pharmacies and the pharmaceutical industry in general, providing advantages in terms of safety for patients compared with conventional procedures of parenteral preparation production. The protocol has demonstrated to be a comprehensive and valuable tool in validating, from a microbial point of view, a sterile-compounding technology. This study might represent an important benchmark in developing a contamination control strategy, as required, for example, in the Performance Qualification of the GMP in the case of drug manufacturing.

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.

Qualification of a chemotherapy-compounding robot

KIRO® Oncology (Kiro Grifols, Spain) is a robotic system for automated compounding of sterile injectable drugs including intravenous cytotoxic treatments. The present article describes the qualification procedure applied prior to production phases. Peristaltic pumps which ensure the reconstitution of drugs were tested with water and NaCl 0.9%. The performance of the robot (accuracy and precision) to prepare bags, syringes and elastomeric pumps was evaluated with three placebo solutions (aqueous, foaming and viscous) using gravimetric controls. Microbiological controls were also performed. The pumps met the requirements set for volumes ranging from 5 to 100 mL. A total of 274 preparations was compounded. For the bags, the filling accuracy was within the limit of ±10% from 1 to 48 mL with aqueous solution, from 0.6 to 48 mL with foaming solution and from 5 to 48 mL with viscous solution. For all syringes and elastomeric pumps, it was within the limit of ±10%. The precision was validated for all preparations, except for bags and syringes prepared with 0.6 and 0.25 mL, respectively. The samples of surfaces and air complied with ISO 5 class environment. Among the 24 gloves tests performed, two presented microbiological growth. All Media fill tests were validated. The qualification procedure led us to exclude injections of any active principle volume strictly lower than 1 mL. The microbiological contamination of operators' gloves remains a critical point. Our operators will be made aware of the issue during the training period.

Reducing pharmacy patient waiting time

PURPOSE

Pharmacy services start right from prescribing medicines and continue as the medication's effect is monitored. Hospital and community pharmacy staff promote rational prescribing and medicine use. Consequentially, pharmacy is a complex and busy field. Often there are peak workload hours when patients must wait, which is associated with patient dissatisfaction that may negatively affect patient experience and the organisation's reputation. The purpose of this paper is to enlist techniques, methods and technological advancements that have been successfully employed to reduce patient waiting time.

DESIGN/METHODOLOGY/APPROACH

A database search was conducted in 2017 to locate articles addressing methods and technologies that reduce pharmacy waiting time. The literature revealed various techniques and technologies like queuing theory, tele-pharmacy, evidence-based pharmacy design, automated pharmacy systems (robotics), system modelling and simulation and the Six Sigma method for identifying potential problems associated with increased wait time.

FINDINGS

The authors conclude that various techniques and methods, including automated queuing technology, tele-pharmacy, automated pharmacy devices/machines for quick and accurate filling and dispensing, computer simulation modelling, evidence-based pharmacy infrastructure for smooth workflow and Six Sigma can maintain customer satisfaction, reduce waiting time, attract new customers, decrease workload and improve the organisation's reputation.

PRACTICAL IMPLICATIONS

The authors conclude that various techniques and methods, including automated queuing technology, tele-pharmacy, automated pharmacy devices/machines for quick and accurate filling and dispensing, computer simulation modelling, evidence-based pharmacy infrastructure for smooth workflow and Six Sigma methodology can maintain customer satisfaction, reduce waiting time, attract new customers, decrease workload and improve the organisation's reputation.

ORIGINALITY/VALUE

The authors carried out a literature search and identified the techniques that have been successfully implemented to reduce pharmacy patient waiting time and methods that can identify potential process behind medication dispensation delays.

Microbiological performance of a robotic system for aseptic compounding of cytostatic drugs

BACKGROUND

Compounding of cytostatic drugs requires strict aseptic procedures, while exposure to toxic drugs and repetitive manual movements should be minimized. Furthermore, reuse of vials is desirable to lower the costs. To assess if all this might be safely achieved with a robot, this study aimed at qualifying the aseptic preparation process with the robotic system APOTECAchemo.

METHODS

The aseptic compounding of patient-individual cytostatic solutions was simulated with media fill simulation tests to qualify the performance according to European GMP Annex 1. The contamination in the environment was measured in critical places using settle plates, contact plates, active air sampling and particle counting. Media-fill simulation tests were prepared in 3 production batches. The second part of the study evaluated the microbiological shelf-life of commercial drug vials after repeated puncturing. On six days, fifty syringes of 15 ml media were prepared from the same 50 vials with the robot. After each preparation, vials were covered with an IVA seal upon unloading from the robot to protect them from microbiological contamination.

RESULTS

No microbiological contamination was found in any of the 96 media fill preparations, nor in any of the 300 syringes that were prepared with repeated puncturing. The compounding area met class A limits, while class A criteria were not fulfilled by the contact plates and settle plates placed on the right side of the loading area. There, the average colony forming units (cfu) were 3 and 1.17, respectively, meeting class B criteria.

CONCLUSIONS

Robotical compounding of cytostatic drugs with APOTECAchemo meets the microbiological requirements of the European GMP. In addition, the robot can reuse vials repeatedly and safely, thereby enabling extended usage.

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.

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.

Intravenous Chemotherapy Compounding Errors in a Follow-Up Pan-Canadian Observational Study

Purpose:

Intravenous (IV) compounding safety has garnered recent attention as a result of high-profile incidents, awareness efforts from the safety community, and increasingly stringent practice standards. New research with more-sensitive error detection techniques continues to reinforce that error rates with manual IV compounding are unacceptably high. In 2014, our team published an observational study that described three types of previously unrecognized and potentially catastrophic latent chemotherapy preparation errors in Canadian oncology pharmacies that would otherwise be undetectable. We expand on this research and explore whether additional potential human failures are yet to be addressed by practice standards.

Methods:

Field observations were conducted in four cancer center pharmacies in four Canadian provinces from January 2013 to February 2015. Human factors specialists observed and interviewed pharmacy managers, oncology pharmacists, pharmacy technicians, and pharmacy assistants as they carried out their work. Emphasis was on latent errors (potential human failures) that could lead to outcomes such as wrong drug, dose, or diluent.

Results:

Given the relatively short observational period, no active failures or actual errors were observed. However, 11 latent errors in chemotherapy compounding were identified. In terms of severity, all 11 errors create the potential for a patient to receive the wrong drug or dose, which in the context of cancer care, could lead to death or permanent loss of function. Three of the 11 practices were observed in our previous study, but eight were new. Applicable Canadian and international standards and guidelines do not explicitly address many of the potentially error-prone practices observed.

Conclusion:

We observed a significant degree of risk for error in manual mixing practice. These latent errors may exist in other regions where manual compounding of IV chemotherapy takes place. Continued efforts to advance standards, guidelines, technological innovation, and chemical quality testing are needed.

Robotic i.v. medication compounding: Recommendations from the international community of APOTECAchemo users

PURPOSE

The development of recommendations for advancing automated i.v. medication compounding is described.

SUMMARY

Managing the shift from manual to robotic compounding of i.v. therapies requires an awareness of how automation affects practice and how to best implement robotics into current practice. An international panel of pharmacy professionals, researchers, and technology leaders with experience in i.v. robotics collaborated during a two-day meeting in August 2014 to define a general set of principles to broaden the understanding of the fundamental elements of robotic compounding worldwide. Participants were divided into four working groups (technology and safety; drugs and products; personnel; and facilities and quality) to analyze specific aspects of robotic compounding practice. The four working groups produced an initial list of 92 statements. This list was condensed to 35 statements by consolidating similar and overlapping statements from the different work groups. Participants were surveyed again to assess agreement with the 35 statements and solicit additional clarification. Respondents expressed full agreement with 25 recommendations. Six statements received one or more "don't know" responses, with all other respondents in agreement. Four statements had a combination of "don't know" and "disagree" responses. A total of 32 comments were recorded in free-text fields, including requests for clarification and suggestions for rewording the statements.

CONCLUSION

An international panel of pharmacy professionals, researchers, and technology leaders with experience in i.v. robotics developed a set of 35 recommendations toward a better understanding of the role of automated i.v. compounding in hospital and health-system pharmacies worldwide.

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.