Several instances of leaking chemotherapy were reported at a facility delivering outpatient chemotherapy in Ontario. These leaks occurred at the Clave needle-free connector near the bottom of the primary intravenous tubing set for the Hospira Plum A+ pump. To mitigate these leaks, the facility implemented the Spiros closed male luer. Despite implementing this technology, leaks continued at the facility.
Using a variety of data collection and analysis techniques such as informal interviews, in-house experiments and a cause and effect analysis, the HumanEra team investigated the underlying technical issues that may have contributed to this series of leaks.
Potential factors identified that may have contributed to the leaks included:
In addition to these factors, other circumstances likely played a role in perpetuating the issue at the primary facility including a delay in communication between front-line staff and management, and inconsistent use of personal protective equipment by front-line staff.
Health Quality Ontario
Griffin, M., Easty, A., (2012). Chemotherapy Exposure and Closed System Drug Transfer Devices.
University Health Network
Melissa Griffin (lead)
Arthur Sivadon (student)
Rossini Yue (student)