In June 2018, Cancer Care Ontario (CCO), the provincial agency that monitors the standard and quality of cancer care, notified us that our “closed system” practice for delivering specific IV medications may have resulted in a reduced dose for some patients, due to more than the expected amount of drug remaining in the IV tubing. This issue is limited to specific drugs provided in small-volume bags of 50 mL or 100 mL. Cancer Care Ontario has indicated that 28 hospitals across the province have been affected.
As soon as we became aware of this issue, we took immediate steps to ensure our patients receive their full dosage while also ensuring safe handling of these medications by staff. We then began notifying active patients of the issue and the change in our practice, which includes a flushing of the IV tubing to ensure any remaining medication in the tubing gets to the patient. All affected patients in active treatment have been directly notified of the issue.
Many intravenous medications require unique processes and equipment, such as pumps, filters and IV tubing. The equipment and set-up can vary based on a number of factors, including the medication itself and the needs of the patient being treated. The “closed system” practice for administering specific IV drugs to patients in Cancer Care is aligned with the standards set by Cancer Care Ontario, and was developed and implemented to ensure that these drugs are safely given to patients without having adverse effects on those who are handling and providing the treatments on a daily basis.
It is important to note that no two patients are alike, and that physicians in cancer care monitor each patient’s individual progress throughout their treatment and in follow-up appointments, and will make medication adjustments as needed based on medical assessments and the patient’s test results. Our physicians have reviewed each patient’s case to determine whether any change in treatment was required. Only one patient has received a supplementary dose of medication.
We are working with other hospitals, with the Durham Regional Cancer Centre and with CCO as they lead a root cause analysis to determine what factors might have contributed to this issue.
Patients who have any questions or concerns related to their treatment are invited to contact us at 705-876-5151 and leave a confidential voicemail. Calls to this line will be returned within two business days.
