Ten years after SA chemotherapy dosing error, survivor fears insufficient changes to prevent future mistakes

ABC NEWS (Australia)

Ten years after a chemotherapy dosing error in South Australia, one survivor is worried that insufficient changes have been made to prevent similar mistakes. Bethanie Alderson reports from Adelaide.

Transcript

00:00A decade ago, 10 leukemia patients were given one daily dose of a chemotherapy drug when

00:07they should have been given two, either here at the Royal Adelaide Hospital or the Flinders

00:11Medical Centre over a six-month period.

00:14Following that underdosing, four patients died, which sparked a coronial inquest.

00:18The deputy coroner at the time found that the error was caused by the treatment protocol

00:22being entered incorrectly into the hospital's systems.

00:25But he also slammed SA Health's incident reporting system and recommended it be abandoned

00:30and replaced with one that reports adverse events immediately.

00:34He said it initially wasn't used at the Royal Adelaide Hospital and failed to prevent further

00:38incidents at Flinders because staff simply weren't checking their emails.

00:43That ultimately led to the underdosing of surviving victim Andrew Knox and five years

00:47on he believes that the system which is used for raising medical issues remains flawed

00:51and is continuing to put lives at risk.

00:54SA Health ultimately decided not to replace the system after it conducted a review in

00:582019 which found it was sufficiently flexible to deliver the recommendation.

01:03But that review also found that clinicians often received a lack of feedback after raising

01:07concerns causing them to become disengaged with the system.

01:11And the Doctors' Union has told the ABC those issues still exist and there is a lack of

01:15confidence from clinicians in reporting incidents.

01:19SA Health has provided a statement and says it is preparing a tender process to consider

01:23a replacement of its incident reporting system as part of its ongoing review of IT systems.

01:29It says there's been continual review and improvements made to that system and that

01:33all of the remaining recommendations from the Deputy Coroner have been addressed including

01:38the rollout of a new chemotherapy prescribing system which is due to be completed early

01:43next year.

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