Government of South Australia, Department of Health
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22 September 2019

   
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Independent review of chemotherapy treatment - Departmental - 03 December 2008

The Women’s and Children’s Hospital has been in contact with 10 out of 11 cancer patients who received a slightly higher than planned dose of the chemotherapy drug Etoposide Phosphate between January 2005 and October 2008. Attempts are being made to contact the family of the eleventh child, who lives overseas.

Children Youth and Women’s Health Service Chief Executive Officer Gail Mondy was notified of the dosage issue on 17 November 2008, and immediately engaged an independent paediatric oncologist from New South Wales, Associate Professor Marcus Vowels, to review the patients’ medical records.

“Associate Professor Marcus Vowels has advised that, based on reviewing the patient records and his own experience with this drug since it was introduced into clinical practice, that no harm has been done,” Ms Mondy said.

“Families of 10 patients have been contacted and their doctors are discussing their child’s treatment.

“Our key concern is to keep our patients and their families informed and to minimise their anxiety by giving them factual and accurate information about the dosage their child received, and the impact on their treatment.”

The Women’s and Children’s Hospital has identified 11 cancer patients between 1 and 15 years old who received a slightly higher than planned dose of the chemotherapy drug Etoposide Phosphate at some stage during their treatment over the three year period in question.

“The issue was brought to my attention when a new staff member double checked a calculation to better understand the computer program that calculates drug dosages,” Ms Mondy said.

Etoposide Phosphate is an alternative form of the common chemotherapy drug Etoposide. When Etoposide Phosphate is used, the dose must be adjusted by a small amount to take into account the different form of the drug. This small adjustment was automatically made by the pharmacy computer.

In 2005, new treatment protocols were introduced that also contained a manual adjustment. This meant that children being treated on these new protocols had the adjustment made twice, and were given a slightly higher than planned dose.

Since the dosage variation was identified, all chemotherapy calculations have been manually double checked and no patient has received a dose other than intended.

Etoposide Phosphate is used to treat a wide range of children’s cancers including severe forms of leukemia, Hodgkin’s Disease, brain tumours and sarcomas.

Cancer patients who received chemotherapy treatment during the three year period under review can contact their doctor at the Women’s and Children’s Hospital for further information or the Women's and Children's Chemotherapy Info Line on 8161 6180.


For more information Contact CYWHS Public Relations Department Telephone: 08 8161 7164

 

 
 
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