An Unwanted Journey: Day 0283 - Medical Mistakes

This might not have been the best week to learn about a fatal human error in administering fluorouracil to an Edmonton cancer patient. The woman's family has requested anonymity, but the incident occurred in The Cross Cancer Institute of Edmonton, Alberta.

There is a lot to be admired about cancer treatment in Alberta; unfortunately, this mistake by a nurse, who programmed an electronic pump to administer a 4-hour dosage of 5-FU that was intended to be given over 4 days, is likely to eclipse all good news in Alberta for quite a while.

The 43-year-old woman died in the University of Albera Hospital after her body's organs and systems failed. No antidote exists for such a massive overdose. To make the situation even more poignant, her oncologist believed that the woman's chances of winning her battle with cancer were about 75 percent before she was given the overdose (see the Edmonton Journal article).

Another patient with colon cancer is quoted in the article extolling the virtues of The Cross Cancer Institute. That patient has a pump that administers his 5-FU in a 46-hour period much like myself.

I, too, wouldn't hesitate to praise the staff at the Grand River Regional Cancer Centre. But I would also acknowledge that mistakes get made. I would add that it is in the patient's best interest not to depend on medical staff for ensuring that all procedures are being followed correctly, or that dosages are accurate, or even that mechanical issues aren't overlooked. My advice? Ask lots of questions. Document everything being done to you. Don't be afraid to look stupid. Get copies of as many medical records as you can and read them all.

I've seen and experienced medical mistakes and possible oversights including the following:

• a doubling of anti-emetic steroids in "opus" and oral forms
• an oversight in which my PICC line was closed when it should have been opened by a GRRCC nurse
• inclusion of the anus in the field of radiation by one oncologist that was immediately excluded by the succeeding oncologist
• failure to provide a transfusion after a bleeding ulcer until a subsequent hospitalization for pulmonary embolii
• mistakes in prescriptions by a supportive care coordinator after complaints about side-effects of radiation therapy
• incorrect insertion of a bladder catheter causing penile bleeding
• regular lateness in administering drugs and pain killers while hospitalized

The point here is not to chastize medical staff in the hospital or the cancer centre. It is to instruct the patient based on my own experience of both wonderful medical care and medical oversights. Pay attention! If cancer doesn't kill you, medical treatment can!