Development of an inter-radiopharmacy cross-audit tool: evaluation on two hospital sites

Radiopharmacy is a hospital pharmacy activity subject to complex regulations. Ensuring the safety of the radiopharmaceutical drug circuit is a priority. A quality approach is essential. With this in mind, the radiopharmacy at Sainte Musse hospital in Toulon has set up inter-radiopharmacy audits. The principle is based on reciprocity: the auditor becomes the audited. In January 2020, 63 radiopharmacies were contacted for a positioning survey on cross-audits. Radiopharmacists expressed an average interest of 8.2/10. Following this survey, a tool was developed to assess radiopharmacy practice in its entirety. It is based on the texts governing radiopharmacy. Checks are carried out on the efficiency of the documentation system, personnel, the reliability and performance of premises and equipment, the radiopharmaceuticals circuit and aspects relating to hygiene and radiation protection. The tool was tested in 2 hospital radiopharmacies in the PACA region. Initially, each unit was assessed by the site radiopharmacist. Subsequently, a cross-audit was organized between the 2 radiopharmacies. The results showed that in cross-auditing, the auditor's neutrality guarantees a more objective analysis of non-conformities. Peer-to-peer auditing encourages the sharing of experience and helps to find collective solutions to common problems. Last but not least, it enables disparities between practice and regulatory requirements to be highlighted