An injection mix-up that claimed the life of a leukaemia patient at Prince of Wales Hospital was a sign improvements to the hospital system for administering drugs were needed, the Canadian expert heading an investigation into the incident said. On June 15, a 21-year-old woman who had acute lymphoblastic leukaemia was given an injection of Vincristine into her spinal canal, which surrounds the spinal cord, instead of intravenously. She died on July 7. Ian Tannock, professor of medical oncology at Princess Margaret Hospital in Toronto, said the error occurred when two chemotherapy drugs were given to the patient at the same time. Vincristine was supposed to be given intravenously and the other drug, which was not named, by the spinal route. 'What happened was that both drugs were given by the latter route [intrathecally] when only one should have been,' he said. Professor Tannock said Vincristine when given by the spinal route could cause 'devastating effects'. 'It's a wake-up call to really absolutely perfect the system to make sure that guidelines are followed strictly,' he said. Professor Tannock said human error and system flaws were involved. He did not think the mistake was due to work pressure. 'The real task is to try to create a system such that human error is not possible,' he said. The system should be 'something like the airline industry has, where everything is checked as much as possible'. The panel would recommend that in future Vincristine be prepared in a container, making it physically impossible to give by the spinal route. The panel would also take on board 'pretty much all' of the World Health Organisation's recommendations in its global alert issued last week following the Hong Kong incident, Professor Tannock said. Among the WHO recommendations was that the drug should be prepared in small intravenous bags. Professor Tannock said the Prince of Wales Hospital had begun using 'mini-bags' instead of syringes so that the drug could not be administered to the spine. The hospital was also taking steps to try to separate 'by time and place, drugs that should be given into the vein from those that should be given around the spine', he said. The panel was still discussing one or two more recommendations to improve the system for its final report, to be completed in two weeks. It will be submitted to authority chief executive Shane Solomon. Professor Tannock said he hoped their report would be made public. Another panel member, the authority's director for quality and safety, Leung Pak-yin, said a new incident reporting system was being designed to disclose serious medical blunders within 24 hours. Staff would be required to report 10 serious events promptly, such as the wrong patient being operated on, wrong transfusion, foreign objects being left in after surgery and maternal deaths. The authority's complaints system now collated even minor things, which made it difficult for urgent reporting of serious blunders, he said.
