Sunday, September 03, 2006

An Unwanted Journey: Day 0285 - Fixing Mistakes

As I continue to read news articles and reports on the tragic death of Rainbow Lake's Denise Melanson from a 5-Fluorouracil overdose, I have wondered about how hospitals in Canada handle medication mistakes. From a patient perspective, it is not at all clear what policies and procedures are in place to deal with such errors. What initiatives are underway to prevent such mistakes happening in the future? Who is managing and monitoring mistakes at the national level (Canadian health care is largely a provincial responsibility).

Like most cancer patients, I am not particularly interested in assigning blame, especially given the professional care which we receive in our own battles with cancer. I deeply respect and admire the oncologists, nurses, volunteers, counsellors, nutritionists, pharmacists, technical specialists, and administrative staff. Without these people, my life expectancy would be far shorter than it is.

Still, I have a vested interest in knowing that appropriate policies, procedures and guidelines are in place and are currently being re-examined in light of this event, everywhere in Canada, not just in The Cross Cancer Institute in Edmonton, Alberta.

I wrote Friday of my first-hand experience in oversights and errors during my treatment. I don't think most of them are very serious (although I am concerned about possible radiation proctitis afflicting me in the future), but the fact remains that the consequences of medical mistakes are not as important as the recognition and amelioration of the practices leading to such mistakes. Thanks to Google News' listing of articles about the Melanson story, it appears that something is being done, although each story raises more questions than it answers.

The Cross Cancer Institute has already taken steps to remedy the situation. Each patient will have to wait one hour after a pump has been programmed to automatically dispense medication. And a third nurse will be involved in checking the doses. The Institue has also contacted the Safe Medication Practices Canada organization (ISMP) to investigate.

It will be interesting to see what local hosptials and cancer centres do in light of this event. Ideally, their safety teams will consider patient involvement in advisory committees. They should also recommend that patients bring complete, up-to-date medication lists to each and every appointment (see the 100K lives Campaign).

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