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Cancer Patient Dies in Edmonton After Nurses' Mistake Leads to Drug Overdose

Posted on: Thursday, 31 August 2006, 15:01 CDT

By JIM MACDONALD

EDMONTON (CP) - An official with the Alberta Cancer Board apologized Thursday to the family of a cancer patient who died after getting a massive overdose of a chemotherapy drug.

Dr. Tony Fields says the woman's death last week from multiple organ failure and internal bleeding is "a most unfortunate incident."

"This is one of our worst nightmares," Fields told a news conference. "This was a young woman in her forties. A wife, a sister, a mother."

The woman was sent home July 31 from the Cross Cancer Institute in Edmonton with a pump that was mistakenly programmed to administer the powerful drug over four hours instead of four days, as prescribed.

Fields said the two nurses involved are very experienced and highly trained and have been devastated by the error that led to the woman's death. He added there is no indication of negligence.

"These were not people who were cutting corners."

The woman's funeral was held Thursday, but her family had requested that her identity not be revealed.

"They understood this was a mistake, it was an accident," said Fields, adding that the family met with the staff involved who expressed their regrets and apologized.

Fields said both the cancer board and the family are concerned the incident might cause other cancer patients to withdraw from chemotherapy treatments.

"The family did not want to shake the confidence of other patients," he said. "We are doing the right thing by going public and being accountable."

"It's important for our patients to know that if we slip, we will not hide it."

Changes have already been made to prevent a similar tragedy in the future, including having patients remain in hospital for at least an hour after they are attached to a drug pump before being sent home, said Fields.

The dose being administered by portable drug pumps, which had been doubled checked by the two nurses involved, is now triple checked, he said.

The drug the woman overdosed on was 5-fluorouracil. Fields says this drug has been used on chemotherapy patients since the 1950's, but there are several methods of administering it.

The woman had naso-pharynx cancer, where the cavity of the throat and nose meet. She had already received radiation and chemotherapy.

"Her cancer was advanced, but it was not beyond cure," said Fields, the cancer board's vice-president of medical affairs and community oncology. "She was being treated with the expectation of a cure."

Fields said findings of an external investigation by the Institute of Safe Medical Practices will be released in a couple of months.

"We will be looking at every step in this process, including whether there is a safer pump," said Fields. "We hope to maintain the bond with our patients."

The mother of three teenagers died Aug. 22 after nearly three weeks in hospital. Fields says she had returned to the cancer facility several days after the overdose and was immediately informed of the mistake in the dosage.

Fields said her death was not linked in any way to the funding and staffing pressures faced by health-care facilities in Alberta.

"If we had all the money in the world we would have been practising in the same way."

Health Minister Iris Evans was not immediately available for comment, but planned to speak with reporters later in the day.

Liberal health critic Laurie Blakeman also said this doesn't appear to be a case of overworked staff not being able to take the proper amount of time with a patient.

"I think it's a tragedy for the family and the staff that were involved," said Blakeman. "I'm glad to see the cancer board is taking all steps to try and prevent a recurrence of this."

Source: Canadian Press

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