Automated Preparation of Cytotoxic Drugs: the Evidence for an Interface Between the Robot and Computerized Provider Order Entry?

Although hospital pharmacists have to face to many constraints when organising the preparation of injectable chemotherapy products, the delivery of secure chemo preparations on the due time for day hospital patients is a major issue according to patients and healthcare professional expectations. Manual preparation of cytotoxic drugs is often associated with highrisk activities and variable performances, while fullyautomated preparation with robots offer several advantages in terms of quality and reduction of medication errors related to wrong product identification, traceability, and process documentation. Furthermore, process automation reduces occupational exposure, musculoskeletal risks, and repetitive strain injuries of pharmacy technicians. In 2017, the Department of Clinical Pharmacy at our institution launched a call for tenders for two robotic systems for the preparation of cytotoxic drugs. After implementation of the first APOTECAchemo robot in February 2018, a multidisciplinary team comprising pharmacists, engineers, and information technology (IT) specialists started a collaboration to expand the automated platform with the goal of installing the second APOTECAchemo robot. Ideally, in order to further minimise the operatorrelated risks and optimise working efficiency, a bidirectional interface between the robots’ management software and the hospital’s Electronic Prescribing Software (EPS) was considered as mandatory to allow exchange and retrieval of clinical information, but could not be done at this time. Consequently, robot operations required prescription retranscription by pharmacists and chemotherapy product relabelling by technicians guided by clear and strict operating procedures. This complex procedure was against the robots’ capacity of ensuring highstandardised procedures, great repeatability, and limited human intervention. Therefore, in early 2020, pharmacists and the IT team defined the interface specifications. Bidirectional information flow was implemented using Health Level 7 (HL7) standards between the EPS and APOTECAmanager (production management software) in May 2020 after qualification and operational tests. A comparative analysis on robot performances was undertaken by evaluating the number of drug products processed, the number of chemotherapy doses prepared, and the daily robot operating hours. The pharmacy staff involved in the automated process remained identical (two technicians/shift). Data were retrieved from each robot’s embedded statistical tool before (March–May 2020) and after interface implementation (July–September 2020). Overall, during these 6 month periods, 13 746 chemotherapy doses were prepared by the APOTECAchemo robots (95% infusion bags) processing 19 different active ingredients. After interface implementation, both the number of chemotherapy doses prepared and the robot operating hours increased by 40.5% and 61.1%, respectively (figure 1). Powder vials reconstituted with solvent increased by 38.1%. The interface robots–EPS was successfully implemented, thereby enabling improved safety and working efficiency. Robotics demonstrated the ability to automate and secure cytotoxic preparations in an efficient way. Without the interface, prescription retranscription and chemotherapy relabelling were still necessary and associated with a risk of human error. In conclusion, adding a bidirectional interface enabled improvement of patient safety. Fully automated preparation with robotic systems adds significant benefits during the compounding process, streamlining pharmacy workflows and ensuring full documentation and paperless traceability. We recommend that an operational interface between robots and EPS is a prerequisite to eliminating a significant part of the risks related to human error during the preparation process.