Wednesday, May 09, 2007

An Unwanted Journey: Day 0531 - Medical Mistakes Redux

Back on September 1st, 2006, I wrote about my own experiences with medical mistakes; I did so in the context of an Alberta woman's death from a chemotherapy overdose. Recently, Tina, a friend of the deceased woman, Denise Melanson, wrote a comment for that blog entry, indicating that a report was forthcoming about reforms arising in Alberta from the overdose. CBC posted a news article about the overdose yesterday and you can read the entire report here.

Denise had 4 days' worth of fluorouracil delivered to her in 4 hours. She received the chemo on 31-July-2006 and died on 22-Aug-2006 at the University of Alberta Hospital. No antidote exists for an overdose of fluorouracil (as well as cisplatin).

The Institute for Safe Medication Practices did a root cause analysis and determined that there were several factors involved in the overdose. The overdose itself, the poorly designed chemotherapy protocol, and the inability to mitigate the lethal overdose all contributed to her death.

Two things of a personal nature have happened since those terrible events. I finished my FOLFOX chemotherapy treatments in September, and my aunt, who lives in Calgary, is undergoing treatment for melanoma. The events are unrelated except that they revolve around Alberta, chemotherapy, cancer, and medical mistakes.

There is no way I can truly understand what it feels like to receive an overdose of chemo like Denise Melanson. I can only say that my chemotherapy treatment was largely without incident. There were no overdoses, at least of fluorouracil and oxaliplatin, but I was quite sick, especially as the chemo drugs built up in my system over time. Even now, almost 8 months after my final chemotherapy treatment, I still suffer from neuropathy in the feet. I can only imagine what might have happened if I had received an overdose of either drug. My heart goes out to Denise's family and her friends, like Tina.

Both this report, as well as my aunt's continuing battle against melanoma in an Alberta hospital, bring it all back - the fear, the hope, the side effects, the "chemo brain", the total dependence on medical authorities - it all surges back as if it were yesterday.

But despite the need for constant vigilance, despite the need for someone to monitor and manage everything that is done to a cancer patient during treatment (my aunt is now discovering just how fragmented the "cancer teams" of specialists can be), progress is being made. Denise's family and friends will have some comfort in knowing that a medical mistake like the one she suffered is now much less likely in Alberta hospitals. My aunt may receive some comfort as well in the hope that her rare form of melanoma may well be elevated among practitioners doing daily diagnoses of medical problems.

Maybe no miracles, just continuous improvements.

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