Original Article

Comparison of closed systemtransfer devices for turnaroundtime and ease of use

J Oncol Pharm Practice0(0) 1–10! The Author(s) 2018
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DOI: 10.1177/1078155218781900
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Zubeir A Nurgat1, Myer Lawrence2, Tusneem A Elhassan3,
Mohammad Al Nahedh1, Mohamed Ashour1, Dina Alaboura1,
Abdulrazaq S Al-Jazairi1 and Ahmed Al-jedai1,4

Abstract
Objective/purpose: The primary purpose of this study was to compare three closed-system transfer devices withdiffering mechanical interfaces for their suitability for adoption into our daily practice. The secondary purpose was to use
the results of this study to support the selection of one of the closed-system transfer devices, which would suit both thepharmacy and nursing staff at our institution, furthermore promoting the enculturation of international recommendations into our clinical practice.
Study design/methods: The hazardous drug preparation process was observed and timed continuously from themoment the technician started compounding until the finished product was handed to the designated checker by raisinghands. A self-administered, structured questionnaire was used for data collection looking at ease of use of each of thedevices from the perspective of pharmacy technicians and nurses. The questionnaire contained an open-ended 10-point
Likert-type scale of eight domains.
Results/key findings: An improvement in the compounding efficiency of hazardous drugs using PhaSealTM (n ¼ 46),
ChemoLockTM (n ¼ 45), and EquaShieldÕ II (n ¼ 45), when compared respectively against the historical control (n ¼ 86),
was statistically significant (p < 0.001). However, no statistically significant difference among the different closed-systemtransfer devices for preparation of hazardous drugs was observed in our study (p ¼ 0.1).
In terms of ease of use, there was no difference in preference for ChemoLockTM and EquashieldÕ II among thepharmacy technicians with both scoring a mean score of 10 with regard to implementation. While PhaSealTM scoreda mean score of 7.2. Among the nursing staff there was a slight preference for ChemoLockTM over EquashieldÕ II with amean score of 9.2 and 9, respectively with regard to the recommended product, while PhaSealTM scored a mean score of
7.4. Both nursing staff and pharmacy technicians had a preference ChemoLockTM, with a mean score of 10 and 9.6,
respectively in terms of on how easy was each device/system to use and overall impression for pharmacy technicians.
This was followed by EquashieldÕ II with a mean score of 9.8 and 8.6, respectively and then PhaSealTM with a mean scoreof 7.2 and 6.6, respectively. Pharmacy technicians felt there were more steps, packaging and clutter when using PhaSealÕ
in comparison to the other devices. With EquashieldÕ II, the estimation of clutter was higher than that of ChemoLockTM
despite the number of packages being within a similar range.
Conclusion/recommendations: Our study found that with experienced staff, compounding of hazardous drugs withclosed-system transfer devices can be as efficient as or even more so than with the traditional needle and syringe
method. With the lack of statistically significant difference among the different closed-system transfer devices studied, in
addition to the cost, ease of use was one of the factors that decided the products applicability in our institution.

1

King Faisal Specialist Hospital & Research Centre, Pharmaceutical Care
Division, Riyadh, Saudi Arabia
2
King Faisal Specialist Hospital & Research Centre, Nursing Development
and Saudisation, Riyadh, Saudi Arabia
3
King Faisal Specialist Hospital & Research Centre. Research Data
Analyst, Oncology Centre, Riyadh, Saudi Arabia

4

Alfaisal University, College of Medicine, College of Pharmacy, Riyadh,
Saudi Arabia.
Corresponding author:
Zubeir A Nurgat, King Faisal Specialist Hospital & Research Centre,
Pharmaceutical Care Division, Riyadh, Saudi Arabia.
Email: znurgat@kfshrc.edu.sa

2

Journal of Oncology Pharmacy Practice 0(0)Keywords
Closed-system transfer devices, turnaround time, ease of use, cost, collaborative, hazardous drugs
Date received: 28 December 2017; accepted: 19 May 2018

Introduction
The eﬀectiveness of the closed-system transfer device(CSTD) in reducing surface contamination of hazardous drugs (HDs) is well established, with many large
studies validating its eﬀectiveness.1–8 These devices are
known to improve the protective performance of primary engineering controls and are regarded as supplemental to these controls, they do not replace theprotection oﬀered by primary engineering controls.9,10
Numerous guidelines to reduce the risk of HD
exposure to healthcare professionals have been suggested by various international organisations.11–16 The
voluntary nature of these guidelines, together withinstitutional apathy, means that the implementation israrely met with vigour or enthusiasm by healthcare
institutions. In a recent survey by the American
Society of Health-System Pharmacists (ASHP) of US
hospital pharmacy directors concerning their procedures for handling HDs, only 19.0% had conducted
exposure monitoring (e.g., air sampling, wipe sampling)in the past 12 months to assess employee exposure tohazardous agents, and only 28.4% had conducted aformal gap analysis to identify and resolve potential
areas of concern in the handling of HDs.17
Re-evaluation of the risks of environmental exposure to HDs prompted a new general chapter, USP<800> Hazardous Drugs—Handling in Healthcare
Settings, which mandates the use of CSTDs for theadministration of HDs to patients, and also recommends utilization of CSTDs for drug compounding.18
The intent and scope of USP <800> are much broader
than some of the requirements found in the previous
USP <797>, especially for HDs. The use of CSTDs as
an additional safeguard against HD exposure is also
recommended by the Occupational Safety and HealthAdministration (OSHA).19 Although USP is a scientiﬁc
nonproﬁt organization, its standards such as USP<800> are enforced by a variety of local, state, andfederal regulatory agencies in the USA and are also
followed worldwide. In addition, accrediting bodies
such as The Joint Commission survey for compliancewith USP compounding standards in hospitals thatreceive its accreditation worldwide.
Since the publication of the consultation documentof USP <800> in 2014, together with heightenedawareness of handling of HDs, there has been renewedinterest for using CSTDs. A 2017 survey of US hospital
pharmacy directors showed overall 64.9% of hospitaluse CSTD for safe handling of HDs. The use of CSTDs

increased from 41.0% of hospitals in 2011 and from
50.3% of hospitals in 2014.20 Of the hospitals that
use CSTDs, 95.1% use CSTDs during the preparation
phase of HDs, and 82.9% use CSTDs during HDs
administration.20 Lack of administrative support andthe belief that the devices are too complicated to implement, in addition to the cost, were cited as reasons citedfor not employing CSTDs.21 There is also a preconception among pharmacy administration that the introduction of the CSTDs increases the turnaround time. This
conundrum has resulted in reluctance to adopt a CSTD
by many healthcare institutions worldwide.22
It is inevitable that as a result of the USP<800>
which comes into eﬀect in 1 December 2019 theuptake of CSTDs during drug preparation by pharmacy technicians and during drug administration bynursing staﬀ is likely to change, with more nursing
departments having access to CSTDs. Thus, carryingout a collaborative evaluation of CSTDs by multidisciplinary teams, to explore the various individualorganisations’ speciﬁcations, will enable vigorous clinical practice before a speciﬁc product is chosen. The
involvement of the end users e.g. Pharmacy
Technicians and Oncology Nurses is imperative inthis evaluation, as a collaborative approach can leadto an eﬃcient and seamless process of reducing inventory cost, training time and avoid duplication of workin evaluation of the CSTDs by diﬀerent stake holders.21
The National Institute for Occupational Safety and
Health (NIOSH) deﬁnes a CSTD as a ‘‘drug transfer
device that mechanically prohibits the transfer of environmental contaminants into the system and the escapeof hazardous drug or vapour concentrations outside thesystem.’’11 Though CSTDs are approved medical
devices, unlike medicinal products, they lack detailed
information from regulatory agencies about thedesign, eﬃcacy, and limitations of each product.10
Of the CSTDs available, there are three broad classiﬁcations.23 The ﬁrst is a full containment, diaphragmbased system, similar to the systems used by PhaSealTM(the innovator product), SmartSiteTM VialShield,HaloÕ and a second-generation product from ICU
medical, ChemoLockTM. The second can be broadlyclassiﬁed as a compartmentalized-based device, suchas EquashieldÕ I/II where there is no external additional piece to the system. The third is referred to as
the air-cleaning technology device, such as OnGuardÕ /TevadaptorÕ . CSTDs can be further subclassiﬁed
according to the basic types of mechanical interfaces
a device can have within itself. PhaSealTM, EquashieldNurgat et al.
I and IIÕ are examples of devices that use a membraneto-membrane mechanism with a needle. ChemoLockTM
is a classic example of a needleless mechanism, whichforms a common ﬂuid/vapour channel, basically without the use of a needle.23
The primary purpose of this study was to compare
three CSTDs with diﬀering mechanical interfaces fortheir suitability for adoption into our daily practice.
The three CSTDs evaluated had Food and Drug
Administration’s (FDA) 510(k) clearance, plus 2012
ONB product code as well as Food and Drug
Administration (FDA) patient administration (FPA)
applications (product code FPA).24 The secondary purpose was to use the results of this study to support the
selection of one CSTD, which would suit both thepharmacy and nursing staﬀ at our institution, andencourage the enculturation of international recommendations into clinical practice. The study received
ethics approval from the Oﬃce of Research Aﬀairsof the corporate organization (Proposal # 2161095;
ORA/0933/37).

Methods
At our institution, approximately 75,000 doses of sterile
parenteral HDs are prepared each year, throughmanual compounding and using chemotherapy compounding robots.25 The bulk of the data collection
was carried out in the cancer Ambulatory Infusion
Centre (AIC), where approximately 50% of all theorganizational HDs are prepared daily (>175/day), inClass II biological safety cabinets (BSC) biologicalsafety cabinets (BSC) located in a negative pressureclean room. The remainder of the data collection was
carried out in the paediatric AIC, where approximately
20% of all HDs are compounded, in satellite pharmacies where 20% are prepared, and in a central inpatient
sterile preparation room where 10% are prepared.
Prior to conducting the study, the company representatives of each CSTD were invited to train the staﬀ
in the technique of using each device with didactic lectures followed by interactive sessions, and hands on
demonstration. The competency of the staﬀ in using
the CSTD was conﬁrmed by the representatives ofeach company. The samples were provided free ofcharge by the company representatives with the fullknowledge that it would be compared with other
CSTDs. No representative from the company participated in any stage of the data collection.
The primary investigator studied the previous methodology,25 from our historical control and adopted thetiming process based on that to reduce variability intiming. The same observer timed all infusions foreach individual so there could be no observer variability. Observations for the historical control took place at

3various times on six randomly selected days without
notifying the selected staﬀ members in advance.
Pharmacy technicians with experience in the aseptic
preparation of compounded sterile products wereselected to participate in the study. All had completed
annual aseptic training courses. Antineoplastic medication doses prepared in intravenous (IV) syringes, andchemotherapy IV bags were included in the evaluation.
For the experimental arm of our study, ﬁve experienced pharmacy technicians and four experienced
nurses’ trialled all three CSTDs. The ﬁve pharmacy
technicians were timed when fully garbed with
Personal Protective Equipment (PPE) during the preparation of the HDs inside the BSC, and the four nurses
were timed, fully garbed with PPE during the administration of the HDs. The preparation process wasobserved and timed continuously from the moment
the pharmacy technician started compounding until
the ﬁnished product was handed to the designatedproduct checker. The data collection took place overthree weeks, with the ﬁrst week allocated to the
PhaSealTM, the second to EquashieldÕ II and the third
to ChemoLockTM. The times were recorded on a data
sheet for that speciﬁc chemotherapy preparation/
administration, and the pharmacy and nursing staﬀ
were asked to ﬁll out the rest of the sheet after simulations had been completed.
A self-administered structured questionnaire,
adapted from Kicenuik et al.26 with the author’s permission, and inclusive of a new section for nurses(Supplementary Appendices 1 and 2), was used fordata collection for ease of use (EOU) of each of thedevices. The questionnaire contained an open-ended
10-point Likert-type scale of eight domains, including
demographic data, for both nursing staﬀ and pharmacy
technicians. The standardized questionnaire was rated
on a Likert-type scale to produce numbers that could
be easily interpreted. Thematic coding was not used tocollate the qualitative responses, nor did we set a minimum threshold to determine if a product was easy touse. Rather we chose the highest value recorded on the
Likert-type scale when choosing the EOU of the
CSTDs. In addition, the staﬀ were not aware of any
threshold prior to participating in the study.
Before data coding and entry, co-investigators
reviewed and checked each questionnaire for completion, accuracy, and consistency. Analysis of the data
was carried out using the Statistical Package forSocial Sciences (SPSS) version 20 software package.
The primary statistical analysis was descriptive innature and included interquartile range, and median,and standard deviation (SD). Box–Whisker plots wereused to show overall patterns, with spacing between thediﬀerent parts of the box to indicate the degree of
spread, any skew in the data, and any outliers, which

4

Journal of Oncology Pharmacy Practice 0(0)were plotted as individual points. Secondary analysis
was performed using nonparametric tests for independent samples, with the Mann–Whitney test for two-sided
independent samples at the 5% signiﬁcance level for thecomparison of the three CSTDs and the control.
In the adult infusion centre, the focus was on two
regimens-ABVD (doxorubicin, bleomycin, vinblastine,and darcarbazine) and EC (epirubicin and cyclophosphamide), which were chosen because they contained
IV piggyback, IV push (bolus) preparations, and thevials were either in powder form or solution. To ensure
we gained enough samples, and that pharmacy technicians got hands on experience in using the devices, we
also made some single preparations utilizing the CSTDs.
In the paediatric infusion centre, the variety of medications prepared was much smaller, so all the cytotoxic
medications compounded during the study day, utilized
the CSTDs. Each week the same medications, predominantly cytarabine, vincristine, and cyclophosphamide,
were compounded in similar doses. The compounding
process itself was timed by a third party, following thesame process as used in the AIC. The same individual
timed every preparation used in the trial so there could
be no observer variability. We measured three diﬀerent
products in real time within the two pharmacies using
predominantly the same medications and the same regimens to ensure comparability. We also used the same
pharmacy technicians to increase the reliability, not onlyof the preparation times, but also to add validity to opinions on each device.

Results
A total of 136 preparations were recorded, 45 for
PhaSealTM, 46 for EquashieldÕ II and 45 for
ChemoLockTM. These preparations were recorded per
medication, and the medications were timed in seconds.
Figure 1 shows the preparation time of the HDs utilizing the CSTDs with 50 percentile (median), ﬁrst quartile (25 percentile) and third quartile (75 percentile).
Results show there was no statistically signiﬁcant difference amongst the three diﬀerent CSTDs for preparations of HDs (p ¼ 0.1). Outliers are plotted as
individual circles and extreme outliers are plotted as
individual stars for the CSTDs tested in Figures 1 to 4.
Figures 2 to 4 show compounding of HDs using
PhaSealTM (n ¼ 46), ChemoLockTM (n ¼ 45), andEquashieldÕ II (n ¼ 45) against the historical control(n ¼ 86). In every case the time diﬀerence of the preparation of the HDs using the CSTD against the historical control was statistically signiﬁcant (p < 0.001). The
median preparation time for the sterile compounding of
HDs was 76 s utilizing EquashieldÕ II (SD 120.32), 80 s
using ChemoLockTM (SD 64.76), and 122 s using
PhaSealTM (SD 129.98). ChemoLockTM had a lower
minimum and maximum timing than the other two

700
72

p-value = 0.1

35

600

24

Time (Seconds)

500
84

400

31
27

69

28

119

300

200

100

0
PhaSealEquashield

Figure 1. Box-whisker plot of compounding of HDs using different CSTDs (n ¼ 136).

ChemolockNurgat et al.

5

P-value <0.001

700
35

600

24

Time (seconds)

500
82

400

31
27

71

28

300

200

100

0
PhaSealControl

Figure 2. Box–Whisker of compounding of HDs using PhaSeal (n ¼ 46) vs. control (n ¼ 86).

400

Time (seconds)

300

82
71

P-value <0.001

28

200

100

0
ChemoLockControl

Figure 3. Box–Whisker of compounding of HDs using ChemoLock (n ¼ 45) vs. control (n ¼ 86).

6

Journal of Oncology Pharmacy Practice 0(0)P-value <0.001

700
27

600

Time (seconds)

500

400

24
39

83
72

300

200

100

0

Control

EQUASHIELD

Figure 4. Box–Whisker of compounding of HDs using Equashield (N ¼ 46) vs. control (N ¼ 86).

10
9
8
7
6
ChemoLock
5

Equashield4

Phaseal32
1
0Pharmacy technician

Nursing staff

Figure 5. Mean values of the CSTD recommended by nursing staff/implementing by pharmacy technicians?
0: Bad; 10: Excellent.

products and only one outlier, the data were also muchless spread out with this device.
Figure 5 shows the mean values recommended bynursing staﬀ, and implementing of the CSTDs by pharmacy technicians. There was no diﬀerence in preference
for ChemoLockTM and EquashieldÕ II among the pharmacy technicians with both scoring a mean score of 10.

While PhaSealTM scored a mean score of 7.2. Amongthe nursing staﬀ there was a slight preference for
ChemoLockTM over EquashieldÕ II with a mean scoreof 9.2 and 9 respectively, while PhaSealTM scored amean score of 7.4.
Figure 6 shows nursing and pharmacy technicians’
having a preference ChemoLockTM, with a mean score

Nurgat et al.

7

10
9
8
7
6
ChemoLock

5

Equashield4
Phaseal32
1
0Pharmacy techniciansNursing staff

Figure 6. Mean values on how easy each device /system to use for nursing staff and overall impression of the CSTD for pharmacy
technicians? 0: Bad; 10: Excellent.

6
ChemoLock
Equashield5

PhaSeal

4

3

2

1

0
No. of steps

No of packages

Estimation of clutter

Figure 7. Mean vlaues recorded from the Likert-type scale on factors affecting ease of use in pharmacy. Mean values recorded fromthe Likert-type scale.

of 10 and 9.6, respectively on how easy was each device/system to use for nursing staﬀ, and overall impressionof the CSTD for pharmacy technicians. This was followed by EquashieldÕ II with a mean score of 9.8 and
8.6, respectively and then PhaSealTM with a mean scoreof 7.2 and 6.6 respectively.
Figure 7 shows that the pharmacy technicians felt
there were more steps, packaging and clutter whenusing PhaSealÕ in comparison to the other devices.
With EquashieldÕ II, the estimation of clutter was
higher than that of ChemoLockTM despite thenumber of packages being within a similar range (twoto three packages per compounding).

Discussion
Initially, the thought of pharmacy technicians having tojuggle additional pieces of equipment for preparation of
HDs was worrying; however, our study showed a statistically signiﬁcant reduction in the median turnaroundtimes of preparation of HDs using CSTDs, indicating it
is more eﬃcient and this is sound justiﬁcation for8adopting the use of CSTDs into our practice. In fact,
our study concurs with previous ﬁndings; that compounding with CSTDs can be as eﬃcient as if not
more eﬃcient than compounding with the traditional
needle and syringe method.27
Although our results show variability in the timerequired for compounding using the three CSTDs evaluated, the lack of a statistically signiﬁcant diﬀerence
hindered the decision-making process. It would
have been much easier to disregard a product that
had a signiﬁcantly negative impact on productivity compared to other CSTDs, making it a non-cost-eﬀective/resource appropriate option. The
diﬀerences in the mean preparation times and thenumber of outliers could be a reﬂection of how easily
the product was to manipulate, the more outliers thegreater variation in preparation time due to the numberof pieces or variability of equipment needed.
EOU could be one of the factors that decided the
products applicability especially if the costs of the
CSTDs are competitive, as there is no signiﬁcant diﬀerence between them when looking at eﬃciency. For thepharmacy technicians, the process of compounding canbe impacted positively or negatively by packaging, clutter in the workspace, and adding or subtracting steps inan established process. We found that there were more
steps when using the PhaSealTM device in comparison
to the other devices. With EquashieldÕ II the estimationof clutter was higher than that of ChemoLockTM despite the number of packages being within a similar
range. As reﬂected in the results, the additional steps
required when utilizing the PhaSealTM had a negative
impact on the timings of the preparations. Others
described more diﬃculty in learning how to use
PhaSealTM than other devices they tested, and themore numerous steps involved in operating the
PhaSealTM system, as an additional barrier to using
this device.6
The technological advancements of CSTDs have led
to improved design, and user-friendliness, giving theman advantage over the older generation CSTDs, whichhave neither changed in design or functionality since
their conception. It is, therefore, not surprising that
PhaSealTM, being the innovator CSTD, was perceived
poorly in terms of EOU by both the nursing and pharmacy technicians. They indicated that the ‘‘push-turnpush’’ mechanism of PhaSealTM was diﬃcult to use atﬁrst. Other participants found PhaSealTM more diﬃcult
to learn how to use, as well as having a greater numberof steps.6
The three devices we studied had diﬀerent safetymechanisms for ensuring the syringe couldn’t be accidently disengaged during compounding and administration. With EquashieldÕ II, the syringe is bonded tothe closed system and is purchased as a complete

Journal of Oncology Pharmacy Practice 0(0)package. Nurses, especially those with smaller hands,
found the IV push administration very diﬃcult to use as
the ability to hold the plunger steady throughout
administration was very tiring. Also because theclosed system was already bonded to the syringe andthe containment system used compartmentalisation, thesyringes were much larger than those used to compound IV push medications normally.
Another attribute that varies between the threedevices is the closing mechanism, and the risk it poses
when administering HDs. Prior to the nurses beginningto push the HD via a syringe or start the infusion bag
via an infusion pump, they need to know the connection is secure and there is no risk of leakage; thisencourages conﬁdence, and therefore products areoften known by the mechanism they utilize for asecure connection. When using ChemoLockTM, one
nurse commented ‘‘I like the sound of the ‘click’, reassuring me that it’s secure.’’ Another commented thatthe clicking noise is a positive attribute to the device,stating ‘‘it clicks on and oﬀ indicating good connection
and release.’’ EquashieldÕ II had two positive responses
related to its closing mechanism, not speciﬁcally the‘‘colour-to-colour, slide’’ alignment strategy, but thatthe equipment itself felt secure.
Those devices that utilize a ‘‘needle safe’’ approachrather than a ‘‘needle free’’ pose the risk that if thedevice malfunctions there is still a needle present andcould cause needle stick injury. The ChemoLockTM
does not involve any needles, increasing its safety
for use, which is in line with many medical
devices available today that are trying to reduce theuse of needles, and thus, reduce the risk of needle
stick injury. However, the mechanism behind the ﬂuid
ﬂow, whether it involved a needle or was needle free,
did not seem to have any impact on the participants’
preference. In fact, there was no reference to any difference between the devices, and whether there was aneedle inside the device did not impact on the pharmacy technicians’ ability to manipulate the products
as required. The two recommended systems utilized
both ﬂuid ﬂow techniques; ChemoLockTM being aneedle-free elastomeric double membrane system andEquashieldÕ II a membrane to membrane with needle
included.
There is a large variability in the manufacturers ofHDs, which in turn means that the medication is often
presented in diﬀerent vial sizes with diﬀerent neck speciﬁcations. We found it was diﬃcult to connect both
PhaSealTM and EquashieldÕ II devices securely to thevial neck of the Vinblastine used in the ABVD preparation, and this impacted negatively the pharmacy technicians’ ability to withdraw all the medication from thevial. This also detracted from the security of the device,leading to the belief that when preparing this speciﬁc

Nurgat et al.
drug, the system was not actually closed. The issues
with selecting the appropriate sized device for theappropriate vial size also impacted on the pharmacists’ability to draw up the medication in an eﬃcientmanner. Within the PhaSealTM and EquashieldÕ II systems there are several diﬀerent devices for use dependent on the size of the vial neck, which could lead to thebelief that the system is more ﬂexible and will cover agreater number of products. However, what was actually found during the study was that pharmacy technicians had to swap out diﬀerent pieces of equipment
when they did not ﬁt properly. This was more evident
in the PhaSealTM trial week and is a possible explanation for the increased number of outliers associatedwith PhaSealTM and EquashieldÕ II, which weren’t
seen with ChemoLockTM.
Within the ChemoLockTM system, there were only
two vial devices which needed to be utilised. Most of
the vials utilized the main vial spike, allowing access tovials having 20 mm/28 mm closures and an external balloon to equalize during reconstitution. The other spike
used was designed speciﬁcally for small vials with a
13-mm closure. This device was utilized with theVinblastine vials, which had caused issues with theother two CSTDs. With this solution to the vial neckissue, the pharmacy technicians could withdraw all the
medication from the vial at the same time feeling thesystem was closed and secure; utilization of the entire
vial of HD is a very important factor when choosing asuitable device. During the trial from the observers perspective, it was apparent that the ChemoLockTM
system oﬀered many more solutions to implementation
issues, with some speciﬁc more diﬃcult to utilize
medications. This is a small but important factor
when considering devices with such a large implementation cost. If the eﬃciency of the pharmacy technicians is negatively impacted because they have to ﬁnd
ways to overcome procedural diﬃculties, which theimplementation of the CSTDs has produced, this inturn will be a false economy against the decrease inpreparation time that has been shown against traditional procedures.
There are several limitations to this study. Firstly, it
could be argued that the low number of preparations
timed, the number of drugs prepared, and the limited
number of pharmacy technicians and nurses involved in
the study, does not provide suﬃcient statistical data to
conduct a truly measurable trial and results may therefore be skewed. Secondly, as PhaSealTM was the ﬁrst
CSTD tested, one might expect staﬀ to become moreexperienced in the use of CSTDs as the trial proceeded,becoming better at using them by the time they got tothe ﬁnal product, resulting in faster use of the product.
This could have skewed the results in favour of the
CSTDs that were trialled later. Thirdly, the pharmacy

9technicians’ enthusiasm, in addition to their awarenessof being observed, could have had an impact on their
speed of work, since they were fully informed of thenature of the research.
Our study demonstrated that with experienced staﬀ,
compounding of HDs with a CSTD can be as eﬃcientas if not more eﬃcient than compounding with thetraditional needle and syringe method. With thelack of a statistical signiﬁcant diﬀerence amongst
the diﬀerent CSTDs studied, in addition to the cost,
EOU was one of the factors that decided the products
applicability.
Acknowledgments
The samples of CSTDs were provided to us by local sales
representatives marketing the CSTDs in the country, withno obligation to purchase after our evaluation. In addition,
they were informed of the purpose of our evaluation and gave
permission for us to evaluate their product. They had no role
whatsoever in conducting the research or writing themanuscript.

Declaration of Conflicting Interests
The author(s) declared no potential conﬂicts of interest withrespect to the research, authorship, and/or publication of thisarticle.

Funding
The author(s) received no ﬁnancial support for the research,authorship, and/or publication of this article.

Supplementary material
Online supplementary data is available at http://opp.sagepub.com/supplemental.

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