Multiple cancer patients killed by improperly programmed chemotherapy pump

Thursday, October 11, 2007 by: David Gutierrez, staff writer
Tags: chemotherapy, medical errors, health news

(NewsTarget) At least eight people have been killed in North America due to errors leading to overdose of cancer medications since 2000, most recently August 2006, a report by the Institute for Safe Medication Practices Canada (ISMP) has concluded.

Denise Melanson died on August 22, 2006, less than a month after nurses accidentally programmed her electronic drug-dispensing pump to dose her with four days worth of cancer drugs in only four hours. The overdose caused her organs to fail.

The institute's report recommended that a number of measures be instituted to prevent such accidents from occurring again. For example, the report recommends that the instructions for nurses be simplified -- the method used at the hospital where Melanson died required nurses to perform complex math -- and that machines be programmed to make it impossible for them to dispense lethal doses.

"We can't turn the clock back, but we can at least use the compilation of those previous seven experiences, and our own experience, and especially this very thorough review, to change our own organization," said Dr. Tony Fields of the Alberta Cancer Board.

The report also found that there has been poor information sharing about such errors, and recommended that analysis of such incidents be shared with other hospitals. However, even with such information, it was highly likely that the accident that led to Melanson's death would have still occurred, Fields said.

According to ISMP Vice President Sylvia Hyland, investigators recreating the circumstances that led to Melanson's overdose made the exact same error that the nurses had.

"When we recreated the circumstances ... the same incorrect rate was entered into the pump," she said.

Melanson's family has reached a legal settlement with the Alberta Cancer Board and the Cross Cancer Institute regarding her death.

"The family accepts and understands [that the] death was the result of human error," said Rosanna Saccomani, the family's lawyer.