Phone: 08 8231 4169 | Email: info@hcasa.asn.au | Find HCASA on FacebookFollow HCASA on Twitter

Phone: 08 8231 4169
Email: info@hcasa.asn.au
Find HCASA on FacebookFollow HCASA on Twitter

hca logo

Consumers at the centre of health
in South Australia

Over a period of six months July – December 2014 during the consolidation phase of treatment for Acute Myeloid Leukaemia five patients at the Royal Adelaide Hospital and five patients at the Flinders Medical Centre received a daily dose of Cytarabine instead of a dose twice a day.

An independent review into the incorrect dosing of Cytarabine to ten patients with acute myeloid leukaemia was completed and a report with an Executive Summary and recommendations was finalised in November 2015. Health Consumers Alliance and Cancer Voices SA were members of the independent review process and panel.

The reports are available below.

Executive Summary - Independent review into the incorrect dosing of cytarabine

Full Report - Independent review into the incorrect dosing of cytarabine

 

SA Health commissioned an independent review of the incident notification, management and analysis of the incorrect dosing of chemotherapy for acute myeloid leukaemia (AML) at the Royal Adelaide Hospital (RAH) and Flinders Medical Centre (FMC) in 2015. The review was undertaken by the Australian Commission on Safety and Quality in Health Care and is the second review looking at these significant incidents.

You can find the review report here and read HCA's media statement on the serious issues involved here.

 The independent review panel found that:

  • There was a serious failure of clinical governance at the RAH.
  • Staff had little or no knowledge of the Incident Management guidelines and did not make an incident report in the Safety Learning System (SLS) within the required time frame.
  •  The health services did not provide sufficient education or explanation of system response or policies.
  • Open disclosure was not well thought out or properly planned, nor was the provision of additional support.
  • There was inadequate documentation of the process or planned follow up.
  • Requests by patients/families for further information were not responded to quickly nor was there a process for reporting back to them about changes that had been implemented.
  •  The issue of compensation was poorly managed.

Implementing the Review’s recommendations:
The review panel has made six recommendations, all of which been accepted by SA Health.


 

SA Chemotherapy Prescribing Governance Committee

Closes Wednesday, 29 June 2016

A state-wide committee on chemotherapy prescribing will be established and report to the SA Medicines Advisory Committee (SAMAC), the most senior medicines committee in SA Health. The role of the committee is to ensure a state-wide process for the review of chemotherapy prescription templates, source protocols and decision support tools. This committee will be an important part of new clinical governance structures for cancer care in South Australia.

You can view the terms of reference for this committee here.

To express your interest for this position please email This email address is being protected from spambots. You need JavaScript enabled to view it.  by close of business Wednesday, 29 June 2016. 

A Select Committee of the Legislative Council has been established to inquire into and report on the chemotherapy dosing errors at the Royal Adelaide Hospital and Flinders Medical Centre in 2014 and 2015. The Terms of Reference are available here. HCA has registered interested and Cancer Voices SA will make a submission. We will advise on progress.

HCA on Facebook

HCA on Facebook

nothing about us without us