Peterborough Regional Health Centre has advised 120 cancer patients that they may not have received full dosages of chemo.
In June, Cancer Care Ontario notified 28 hospitals (including PRHC) that their “closed system” practice for delivering three specific IV medications may have resulted in a reduced dose for some patients as some of the drug was remaining in the IV tubing.
The issue was limited to drugs (pembrolizumab, nivolumab, panitumumab) provided in small-volume bags of 50 millilitres or 100 ml. Those drugs are used to treat skin, lung and head cancers or cancers that can’t be removed by surgery.
Dr. Lynn Mikula, chairperson of the PRHC medical advisory committee, says the hospital has treated more than 50,000 cancer patients over the past decade and that immediate steps were taken to ensure patients received their full dosage.
“We take it very, very seriously but this is not something that’s affected the majority of patients by any stretch,” she said.
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PRHC also ensured staff were properly handling the medications.
“We then began notifying active patients of the issue and the change in our practice, which includes a flushing of the IV tubing to ensure any remaining medication in the tubing gets to the patient,” PRHC stated.
“All affected patients in active treatment have been directly notified of the issue.”
PRHC says equipment and setup can vary for each patient and that the “closed system” is aligned with standards set by Cancer Care Ontario.
The hospital now flushes the tubing with saline solution so all the medication is administered.
“It is important to note that no two patients are alike, and that physicians in cancer care monitor each patient’s individual progress throughout their treatment and in follow-up appointments, and will make medication adjustments as needed based on medical assessments and the patient’s test results,” the hospital stated in a release issued Monday.
“Our physicians have reviewed each patient’s case to determine whether any change in treatment was required. Only one patient has received a supplementary dose of medication.”
The Peterborough hospital says it is working with other hospitals, the Durham Regional Cancer Centre and Cancer Care Ontario to do a thorough root cause analysis to determine what factors might have contributed to the issue.
Patients who have any questions or concerns related to their treatment are to contact PRHC at 705-876-5151 and leave a confidential voicemail.
Cancer Care Ontario says it is also updating its clinical guidelines for the safe administration and handling of systemic treatment.
“We will ensure that learnings from the root cause analysis and guideline update are included in the approved education for specialized oncology nurses delivering systemic treatment in Ontario,” stated Cancer Care Ontario.
More to come.
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