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Pharmacist Assistant Uncovers Chemo Drug Dosage Error

David W. Hodges
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Partner at Kennedy Hodges LLP practicing pharmacy error, medical malpractice and personal injury law
Posted on May 19, 2013

It was recently discovered that over 1,200 cancer patients in two provinces in Canada were taking a watered down chemotherapy drug. On March 20, 2013, around 2:20 p.m., a pharmacist assistant at Peterborough Regional Health Center made this discovery.

When the stock of chemotherapy drugs from the previous supplier ran out, the pharmacy assistant detected that the old drug and the new medication from a different supplier were different. She compared the labels on the bags of the drug mixture from the previous supplier, Baxter, to the new drug supply from Marchese Health Solutions. Although she knew something wasn’t right, the dosage instructions were unclear. Baxter included the concentration of the drug gemcitabine on the labels, but Marchese did not include the concentration on its label. She then had colleagues look at the drugs, and they turned to the company for answers. 

After investigating the change in the drug, they determined that the new supply from Marchese was a diluted chemotherapy drug. While this hospital only had one patient exposed to the watered down chemotherapy medication, other Canadian hospitals in London, Oshawa, and Windsor have been using, in some cases, the diluted drug for a year. The bags from Marchese were less potent by 20 percent.

Cancer Care Ontario has indicated that each step in the drug supply chain increases the chances of a medication error. Now focus is being put on the supply chain and Medbuy, a bulk purchasing agent for the hospital. A review is taking place and has put the provinces’ cancer drug system under the microscope.

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