[Evaluation of practices through simulation: Implementation of Horror Week in a cytotoxic preparation unit]

OBJECTIVES

The objective of this work is to describe the interest of developing a simulation for the evaluation and improvement of practices through the realization of a horror week in a cytotoxic preparation unit.

METHODS

The simulation was divided into five days, each corresponding to a step in the cytotoxic circuit. Five errors per day were produced and presented to the team in a dedicated room. An observation form was used to collect the errors identified by each person. A satisfaction questionnaire was distributed and a collective debriefing took place remotely.

RESULTS

The average number of errors identified per day was 3.8. The least common errors were reversal of patient height and weight, overloading of the sterilization basket, failure to follow dressing rules in the controlled area, absence of the temperature-monitoring disk, and absence of an opaque bag for photosensitive chemotherapy. The perceived level of difficulty was 3.33/5 and the organization was satisfactory to all participants.

CONCLUSIONS

Horror Week achieved its objectives by raising awareness among professionals of the risks of the chemotherapy circuit. The errors that were found to be the least significant allowed us to develop priority areas for ongoing training for our unit.

[The quality manager in radiation therapy: Evolution of the role, presentation of a French national Survey]

PURPOSE

Review the role of the quality manager 15 years after ASN Decision 2008-DC-103 and 10 years after the creation of the Association française de la qualité et sécurité en radiothérapie (AFQSR), taking into account the new regulatory framework introduced by ASN Decisions 2021-DC-708 and 2019-DC-660.

MATERIALS AND METHODS

a survey was drawn up and distributed to members of the French association for quality and safety in radiotherapy.

RESULTS

The role of the quality manager in radiotherapy is one of the pillars of the quality/safety approach introduced by ASN Decision 2008-DC-103.

CONCLUSION

The hierarchical position of the quality manager needs to be better defined, as does the notion of authority. The time and resources allocated to the function and to the quality/safety approach also need to be adapted, as these are the main factors of tension identified by the survey. The publication of ASN Decision 2019-DC-660 has extended the scope of the quality manager to include imaging in several centers.

[Uterine rupture during medical termination of pregnancy or intrauterine death: A risk management study]

OBJECTIVE

To describe and analyze a series of uterine ruptures (UR) that occurred in the context of medical termination of pregnancy (MTP) or intrauterine death (IUD) from a risk management perspective.

METHODS

French retrospective descriptive observational study of all cases of UR occurring during induction for IUD or MTP, reported between 2011 and 2021 by Gynerisq. Cases were recorded on a basis of voluntary reports using targeted questionnaires.

RESULTS

Between November 27, 2011, and August 22, 2021, 12 cases of UR occurring during an induction for IUD or MTP were recorded. 50 % of the patients had never given birth by cesarean section. The term of delivery varied from 17+3 days to 41+2 days. The clinical signs found were pain (n=6), ascending fetal presentation (n=5) and bleeding (n=4). All patients were managed by laparotomy, 5 were transfused. One vascular ligation and one hysterectomy were required.

CONCLUSION

Knowledge of surgical history is involved in the prevention of UR. The signs of detection are pain, ascending presentation and bleeding. The speed of management and good teamwork allow a reduction of maternal complications. The findings of the morbidity and mortality reviews show that prevention and mitigation barriers can be established.

[Radiation TherapisTs Radiographer (RTTs) and risk management in radiotherapy: An international survey]

PURPOSE

In order to study the role perception and the effective involvement of Radiation TherapisTs (RTTs) in risk management in radiotherapy, a survey was developed and distributed in five countries (France, Switzerland, Belgium, Ireland, the Netherlands).

MATERIALS AND METHODS

The article presents the results of this survey and the comparison between the different countries.

RESULTS

Overall, the results of the survey show a good involvement and perception of the RTTs around the risk management approach, although training in this area has yet to be systematized.

CONCLUSION

Although with differences in the results between the participating countries, the survey seems to highlight the deployment of preventive actions that are evaluated as not very effective by the respondents and by the international scientific literature.

Quality/risk management system in radiotherapy: Changes afoot

The French sanitary and regulatory context in which radiotherapy centres are comprised is evolving. Risk and quality management systems are currently adapting to these evolutions. The French nuclear safety agency (ASN) decision of July 1st 2008 on quality assurance obligations in radiotherapy has reached 10 years of age, and the French high authority of health (HAS) certification system 20 years now. Mandatory tools needed for the improvement of quality and safety in healthcare are now well known. From now on, the focus of healthcare policies is oriented towards evaluation of efficiency of these new organisations designed following ASN and HAS nationwide guidelines.

On-call duties in hospital pharmacies: National survey and elaboration of a training program for pharmacy residents

OBJECTIVES

During their residency, pharmacy residents are required to attend a hospital on-call program in order to insure the continuum of care for inpatients. This activity is subject to risks, and requires a prior training. Our aim was to develop and to optimize such a training program.

METHODS

To this end, we first established a baseline study of the existing training methods in our hospital and those in the different hospitals of France in which pharmacy residents realize in-house on-call duties, associated with an identification of both pharmacists and students' needs in our institution. These preliminary studies were used to create a transversal, structured and harmonized training program.

RESULTS

The results of our national survey highlighted great disparities of training between the establishments and point out the lack of structure, organization and harmonization of the training, which residents expected to be improved. Our training program contains 3 parts: initial theoretical training, initial practical training and continuous training. Beyond the harmonization of the theoretical training's materials between the different sectors of the pharmacy, new tools were introduced like an in-house on-call duty notebook complementary to trainings adapted to note taking, simulation's workshops and interactive quizzes. The training was gradually implemented in our hospital pharmacy, in collaboration with the pharmacists of the different activity sectors.

CONCLUSIONS

The next steps of our work will be to assess pharmacists and pharmacy residents' satisfaction about our program and its efficacy.

[Medication errors in Auvergne-Rhône-Alpes: A prospective pilot study led in collaboration by regional vigilance and support structures]

Medication errors (ME) are frequently encountered and present at every step of the therapeutic process. This study's aims were to take stock of the ME reported to the region's pharmacovigilance (CRPV) and poison control centers (CAPTV) and to identify potential regional actions. A 2-months (January and February 2017) prospective gathering of the calls to the CAPTV regarding the ME and of the ME declarations to the region's CRPV (Clermont-Ferrand, Grenoble, Lyon, Saint-Etienne) has been carried out. The place of occurrence, the event's description and its consequences and data regarding the patient were collected. In addition to that, the regional drug observatory OMEDIT analysis has allowed to determine the ME's types (REMED characterization, never event?) and to look for the results of a potential thorough analysis. The study reported 580 calls for 590 ME and 583 patients. ME mostly affected the ambulatory/domicile sector (76%), the medico-social sector (14%) and the healthcare facilities sector (7%). It usually was about dose errors, medication errors and patient errors with a different profile in each sector. The majority of errors (85%) occurred at the administration step. Almost all the observed ME were confirmed errors having reached the patient (99.5%) but only a few had serious consequences. One out of 5 ME was eligible for a thorough analysis but even less were subjected to that kind of analysis. The main never event concerned the unidose in the ambulatory sector. The health products involved were mostly a single medication (75%) and then the patient's full treatment (12%). The CRPV/CAPTV/OMEDIT's skills are complementary for the gathering, the analysis and the management of the ME. Training campaigns and support are to be considered for the professionals and especially within the medico-social facilities.

[Organization and risk management in stereotaxic body radiotherapy at the treatment station]

The development of stereotaxic body radiotherapy in the last decade has forced the radiotherapy departments to redouble their efforts in the fields of quality and risk management. For this purpose, increasingly complex and rigorous controls of high performance machines as well as a solid team training must be put in place. Extreme hypofractionation requires both increased vigilance at the treatment desk and well-defined and known procedures. The in place organizations contribute to the control of the risks related to the stereotaxic body radiotherapy machines. The medical presence at the beginning of the treatment fractions has been specified as mandatory in a regulatory way since January 2017. This not only ensures security, but also transmits information to the radiation therapy technicians. At the Eugène-Marquis center, the skills of the technicians for stereotaxic body radiotherapy on two dedicated machines (Cyberknife^® and Versa HD^® Novalis^® type) have been upgraded. An accreditation is formalized after a training period and re-evaluated annually. The communication inside and outside the radiotherapy field plays also an important role in maintaining a high level of exchange and sharing of essential information. The means implemented at the Eugène-Marquis center increase the risk control of SBRT, by paying attention to the management of skills at the treatment station.

[Implementation of experience feedback committees meetings between the radiotherapy centres of Northern France by the regional oncology network]

Onco, the Regional oncology network of Northern France, in partnership with Cronor, is piloting a project to harmonize radiotherapy practice. In 2016, a working party "Quality in Radiotherapy" was set up to encourage all centres in the network to participate in regional experience feedback committees. These committee meetings allow for analysis and handling of adverse events in radiotherapy within predefined areas of expertise. The purpose is to formalize and issue recommendations based on good practice by the use of regional bulletins. This article details how such experiential feedback committees are implemented, what they can contribute and the barriers to such work at each stage of the project.

[Global risk management]

Risk management is a fundamental component of any successful company, whether it is in economic, societal or environmental aspect. Risk management is an especially important activity for companies that optimal security challenge of products and services is great. This is the case especially for the health sector institutions. Risk management is therefore a decision support tool and a means to ensure the sustainability of an organization. In this context, what methods and approaches implemented to manage the risks? Through this state of the art, we are interested in the concept of risk and risk management processes. Then we focus on the different methods of risk management and the criteria for choosing among these methods. Finally we highlight the need to supplement these methods by a systemic and global approach including through risk assessment by the audits.

[Security of the medicinal therapy: Cartography of risks a priori within service of orthopaedic surgery]

INTRODUCTION

Security and quality of the Medicinal Therapy are one of the most important objectives of the April 6th, 2011 order. The objective is to realize this study of the risks incurred by patients related to management and security of medicinal therapy in order to establish a plan to reduce the risks of drug's dispensation.

MATERIALS AND METHOD

The method of the Preliminary Risk Analysis (PRA) has been implemented by a multidisciplinary group in a hospital service of orthopaedic surgery. The study focused on the dispensation phase of medicinal circuit.

RESULTS

This analysis revealed 148 scenarii, 35 were criticality unacceptable. Fifty-four initial risk control actions were proposed and their stress levels to put them in place were evaluated.

DISCUSSION

The main measures of risk management are: training, information, communication, computerization, automation, dual control, updating the documentation system, drug reconciliation and respect for Best Practices Hospitallers (BPH).

CONCLUSIONS

Risk management requires a significant human and financial investment as well as, material resources and multidisciplinary expertise in order to offer the best solutions.

[Responsibility due to medication errors in France: a study based on SHAM insurance data]

PURPOSE

The safe medication practices at the hospital constitute a major public health problem. Drug supply chain is a complex process, potentially source of errors and damages for the patient. SHAM insurances are the biggest French provider of medical liability insurances and a relevant source of data on the health care complications.

METHODS

The main objective of the study was to analyze the type and cause of medication errors declared to SHAM and having led to a conviction by a court. We did a retrospective study on insurance claims provided by SHAM insurances with a medication error and leading to a condemnation over a 6-year period (between 2005 and 2010).

RESULTS

Thirty-one cases were analysed, 21 for scheduled activity and 10 for emergency activity. Consequences of claims were mostly serious (12 deaths, 14 serious complications, 5 simple complications). The types of medication errors were a drug monitoring error (11 cases), an administration error (5 cases), an overdose (6 cases), an allergy (4 cases), a contraindication (3 cases) and an omission (2 cases). Intravenous route of administration was involved in 19 of 31 cases (61%). The causes identified by the court expert were an error related to service organization (11), an error related to medical practice (11) or nursing practice (13). Only one claim was due to the hospital pharmacy.

CONCLUSION

The claim related to drug supply chain is infrequent but potentially serious. These data should help strengthen quality approach in risk management.