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.
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.