Over a period of six months July – December 2014 during the consolidation phase of treatment for Acute Myeloid Leukaemia five patients at the Royal Adelaide Hospital and five patients at the Flinders Medical Centre received a daily dose of Cytarabine instead of a dose twice a day.
An independent review into the incorrect dosing of Cytarabine to ten patients with acute myeloid leukaemia was completed and a report with an Executive Summary and recommendations was finalised in November 2015. Health Consumers Alliance and Cancer Voices SA were members of the independent review process and panel.
The reports are available below.
SA Health commissioned an independent review of the incident notification, management and analysis of the incorrect dosing of chemotherapy for acute myeloid leukaemia (AML) at the Royal Adelaide Hospital (RAH) and Flinders Medical Centre (FMC) in 2015. The review was undertaken by the Australian Commission on Safety and Quality in Health Care and is the second review looking at these significant incidents.
The independent review panel found that:
Implementing the Review’s recommendations:
The review panel has made six recommendations, all of which been accepted by SA Health.
SA Chemotherapy Prescribing Governance Committee
Closes Wednesday, 29 June 2016
A state-wide committee on chemotherapy prescribing will be established and report to the SA Medicines Advisory Committee (SAMAC), the most senior medicines committee in SA Health. The role of the committee is to ensure a state-wide process for the review of chemotherapy prescription templates, source protocols and decision support tools. This committee will be an important part of new clinical governance structures for cancer care in South Australia.
You can view the terms of reference for this committee here.
A Select Committee of the Legislative Council has been established to inquire into and report on the chemotherapy dosing errors at the Royal Adelaide Hospital and Flinders Medical Centre in 2014 and 2015. The Terms of Reference are available here. HCA has registered interested and Cancer Voices SA will make a submission. We will advise on progress.