A study was recently published in the Journal of Oncology Pharmacy Practice (JOPP) led by Rachel White, a Human Factors Specialist of HumanEra, a research team here at UHN. The study looked at potential errors that could affect the preparation of chemotherapy medications in Canadian hospitals.
Researchers, including Rachel White, Andrea Cassano-Piché and Dr. Tony Easty (all of HumanEra @ UHN) took a human factors approach and embedded themselves in 6 different hospital pharmacy environments across the country to observe pharmacy practices and to uncover ways in which errors could potentially work their way through the system. No errors were actually observed, rather, those practices that could potentially allow a mistake to sneak through the system were highlighted, so that changes to the system could be made to prevent or minimize the possibility of an error occurring.
Three main potential issues were uncovered from the study including that when there wasn’t a second worker available, double checks weren’t always being done, that having more than one medication in the biological safety cabinet during mixing could lead to a picking error where the wrong medication is chosen and then injected into the mix, and that labels weren’t always attached to the bags that were being mixed, making it possible for the wrong label to be put on a mix.
This report has already brought about positive change in many hospital pharmacies across the country.
Here are links to some of the media buzz surrounding the study so far: