Human error led to cancer patient's death

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Human error led to cancer patient's death
KATHERINE HARDING

From Wednesday's Globe and Mail

May 8, 2007 at 10:42 PM EDT

Edmonton — Denise Melanson's cancer was diagnosed in March of 2006 and, within six months, she was dead. But it wasn't the disease, an advanced but treatable form of cancer of the nasal passage, that killed the married mother of two, but rather the drugs that were supposed to cure her.

Two independent investigations into the 43-year-old woman's death were released Tuesday and documented how a series of human errors led to her receiving a fatal overdose of chemotherapy drugs on July 31.

Less than a month after receiving four days worth of medication in four hours from a misprogrammed electronic pump, the Rainbow Lake, Alta., resident's organs shut down and she was taken off life support on Aug. 22.

In its 81-page report, the Institute for Safe Medication Practices Canada concluded that similar errors have resulted in at least seven deaths at cancer centres around North America since 2000.

The institute has recommended that medication errors such as these need to be more widely reported and shared between health facilities, so they are not repeated.

The Health Quality Council of Alberta, which also reviewed Ms. Melanson's death, also called for more disclosure of medication mistakes.

In her case, the Institute for Safe Medication Practices identified 16 factors that led to the accidental overdose, including a complicated mathematical formula that tripped up two nurses administering her drugs.

According to the report, on July 31 a nurse made the initial error after she misunderstood a pharmacist's prescription and then misprogrammed the electronic pump to disperse fluorouracil, a drug used to treat tumours, over four hours instead of the prescribed four days, along with another chemotherapy drug, cisplatin.

A second nurse double-checked her work, but couldn't find a calculator and ended up doing the mathematical equation mentally and on a piece of paper. She didn't catch the mistake and the electronic pump was then given to Ms. Melanson.

Later that day, Ms. Melanson, a teacher's assistant, returned to the cancer clinic after the pump began to beep and she noticed that the infusion bag was empty.

The institute's investigation revealed that initially there were differing responses from health-care workers about how serious the overdose was, despite receiving a doctor's warning on July 31 that there was no antidote.

Tony Fields, vice-president of the Alberta Cancer Board, said there are plans to adopt as many recommendations from both investigations as possible, and that the reviews into the case will be made available to cancer facilities across Canada.

He added that the cancer board also made procedure changes shortly after Ms. Melanson's death, including having a patient monitored for at least one hour after a drug treatment starts.

Rosanna Saccomani, the Melanson family's lawyer, said that a financial settlement was reached with the Alberta Cancer Board. Neither of the parties would disclose the terms or amount of it.

Ms. Saccomani said Ms. Melanson's family is still grieving, but understands that human errors occur.

She said that the Ms. Melanson, a Nova Scotia native who moved with her family to Alberta in 2005, took the “high road” after she was told about the overdose and the fact there was no cure.

“There was little room in her heart for bitterness and anger.”