‘Typo’ leads to wrong chemo dose for Adelaide cancer patients

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    Jack Snelling and Professor Peter Bardy

Ten leukaemia patients in Adelaide have been given half the recommended dose of a chemotherapy drug due to a typographical error, the Health Minister has confirmed.

The error occurred at the Royal Adelaide Hospital and Flinders Medical Centre between July 2014 and January 2015.

The seriously ill patients were supposed to undergo intensive chemotherapy, but instead only received half the recommended dose of the drug Cytarabine to treat their acute myeloid leukaemia.

This continued for several months and impacted on some patients’ second and third round of treatments until a senior clinician discovered the error.

Patients have since been contacted and SA Health is investigating the incident.

Health Minister Jack Snelling apologised to the patients affected by the mistake.

“This is very, very regrettable and unfortunate for those 10 patients involved,” Mr Snelling said.

“Fortunately these types of errors are incredibly rare in our health system and when they are made they are picked up very, very quickly.”

Mr Snelling said the only explanation for the mistake was human error.

“Our health system deals with about 8,000 people every day and unfortunately human beings make decisions and do things and there’s no human being who is completely infallible,” he said.

Clinical director of cancer services Professor Peter Bardy said a modification was made to the database, which resulted in the typographical error of the drug dosage.

He said since the incident clinicians had implemented further checks of data entry before anything was loaded onto the database to avoid the same mistake from happening again.

Impact on patients’ treatment ‘unknown’

Professor Bardy said it was unknown what impact the mistake would have on the patients’ outcomes.

“It is difficult to know what the impact is for an individual patient because the cure rates for this disease is around 30 to 40 per cent,” he said.

“There is actually no international consensus about the optimal dose of the drug that was given at less than the dose than we’d planned for.

“Our view is probably no impact on individuals, but for the reasons just said it’s difficult to know.”

But in March this year one patient, a man in his sixties, who had been in remission, suffered a relapse.

Legal sources said his family had been tormented by the thought of what might have been if he had received the right amount of the drug.

The man has since received a confidential settlement, but the Government would not say if any of the other patients have been compensated for the blunder.

“We will make sure that any claim that they’ve got will be quickly and readily settled,” Mr Snelling said.