Patients didn’t get full dose of cancer drugs

Review finds 86 patients missed out

WATERLOO REGION — A number of cancer patients receiving treatment through the Waterloo Wellington Regional Cancer Program did not receive their full prescribed medication.

A review dating back to 2009 found 86 patients potentially missed out on at least 10 per cent of some medications administered intravenously because of the way the tubing was set up, said Jane Martin, vice president of the regional program.

Waterloo Wellington patients affected received care at Grand River Hospital, Cambridge Memorial Hospital, North Wellington Health Care Corporation, and Guelph General Hospital.

Martin said oncologists reviewed each case. “After doing the review, there’s only two patients that (oncologists are) considering providing any supplementary treatment for,” said Martin, adding that all patients affected have been informed.

The issue came to light in June, when a healthcare worker at Trillium Health Partners in Mississauga noticed the tubing used to deliver drugs through intravenous therapy was “fairly long,” said Dr. Leta Forbes, head of systemic therapy at Cancer Care Ontario, an agency of the Ministry of Health and Long-Term Care.

“There was more drug than they expected left in the tubing rather than being delivered to the patient,” said Forbes.

Because the intravenous set up didn’t allow for the tubing to be flushed with a saline solution, patients missed out on medications left in the lines.

The tubing set up has affected about 1,000 patients at 29 hospitals across the province. How

they are affected varies based on the hospital’s practice, Forbes said.

Patients reported to be affected were recipients of three particular drugs — two immune therapy drugs and one targeted therapy one.

“We have centres going back and looking at their practice for all of the drugs they administered to ensure that they’re getting as much drug to the patient as possible — and some of those drugs may be chemotherapy drugs,” she said. “The initial three are not but we’re still gathering more information to ensure that people are administered all the drugs.”

Martin of Waterloo Wellington’s regional cancer program said once the program was notified it did a “thorough review of every single patient that may have received the medications in question, from the start of their availability.

“With these particular drugs, the reason they’re an issue is because they’re highly concentrated and they’re given in a small volume,” she said. “So if there’s any variation in the administration then it creates more of an issue.”

Martin said the tubing has also been changed to allow nurses to flush the lines more easily and audits were conducted to make sure the drug administration procedure was being followed.

“We also had a patient letter and a patient information line in case there were any questions for patients,” she said.