Past patients at HHCC administered incorrect chemotherapy dosage

August 24, 2018   ·   0 Comments

By Mike Pickford

After a recent provincial review indicated three former patients at Headwaters Health Care Centre (HHCC) likely did not receive a full dose of prescribed chemotherapy medications, hospital officials have moved quickly to dispel any fears that this was an ongoing concern at the local facility.

Details regarding the incidents, which hospital staff say occurred between June 2014 and June 2016, were first identified in June of this year. Cancer Care Ontario (CCO), the provincial agency that monitors the standard and quality of cancer care, became aware of an issue relating to the administration of three systemic chemotherapy treatment drugs – Pembrolizumab, Nivolumab and Panitumumab – with more than the expected amounts of medications remaining in IV tubing following treatment.

The three patients affected at HHCC have all since died. Peter Varga, the hospital’s Vice-President of Patient Services and Chief Nursing Officer, says a medical oncologist and internal medicine specialist has reviewed the potential clinical implications of each case, concluding it was “unlikely” that a small variation in dosing was a factor in the deaths.

On June 26, CCO issued a safety bulletin to all 74 Ontario hospitals that deliver systemic chemotherapy treatment. It asked hospitals to complete a thorough review of all policies and procedures relating to chemotherapy treatment to ensure patients received their full, intended dosage of medication. In total, 28 of those 74 hospitals across Ontario were affected.

“We took this issue very seriously and immediate steps were taken to review our practices, both past and present,” Mr. Varga told the Citizen. “We completed an internal audit of our medication administration practices, methodologies, equipment, supplies and processes and these have met or exceeded current standards.”

He added, “As part of our hiring practice, we require all nurses who administer systemic therapy to be certified in chemotherapy administration, as outlined by CCO’s nursing credentialing guidelines. Our processes into the future will continue to assess prescribed dosing of chemotherapy in partnership with our pharmacy and clinicians providing chemotherapy.”

In a release to the public, Mr. Varga confirmed this was not an ongoing concern at the hospital, with the last of these incidents occurring in June 2016 at the absolute latest.

“We have no concerns. We have done two audits, one internal and one external with the Mississauga Halton Regional Cancer Program, as well as reviewed all our policies and procedures with our staff,” Mr. Varga said. “We are confident our practice meets the expected standards of IV chemotherapy medication administration.”

When asked how this issue regarding incorrect dosages being administered to patients had occurred, Mr. Varga said it all boiled down to a failure in the system HHCC uses in its chemotherapy treatments.

“Headwaters’ practice is to flush the IV tubing with saline solution so all the medication is administered to the patient,” Mr. Varga said. “High concentration and low volume solutions require an ability to flush the remaining portion of the medication. In this specific case, we identified three patients who were unlikely to have received their full dose of chemotherapy because the system could not be flushed. (As a result) a small portion of the medication remained in the tubing.”

Mr. Varga stated the hospital is currently in the process of identifying next-of-kin of the three affected patients so as to provide them with an opportunity to ask any questions they may have relating to the issue.

“It’s our intent to ensure our community has both trust and confidence in Headwaters when receiving their care. Patients and families can reach out to us if they have any questions or concerns specific to this issue,” Mr. Varga said.

He went on record to thank all HHCC staff for their cooperation and hard work throughout this process.

“I wanted to share my deep appreciation and gratitude to all our Headwaters staff, including our nurses, doctors, pharmacists and managers/directors, who made reviewing this issue their top priority,” Mr. Varga said. “They worked so hard together to help ensure our services meet our patients’ and families’ expectations. I’m especially proud of their dedication in caring for our patients.”

Anyone with any questions or concerns related to their treatment are encouraged to call 519-941-2702 ext. 2551 and leave a confidential voicemail with their name and contact number. Mr. Varga said he will ensure someone from the care team connects with any callers at the earliest opportunity.

For more information about systemic treatment and the medications in question, visit

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