PATIENT SAFETY MEDICAL NEGLIGENCE
Should this Example of Chemotherapy or Radiation mistakes be a Notifiable Incident under the Patient Safety Act.
John Whelan Solicitor with specialist expertise in Medical Negligence and Patient Safety gives an example of cases which falls outside of the definition of a notifiable incident under the Patient Safety Act 2023.
An example of cases of Chemotherapy or Radiation Mistakes
Mistakes in chemotherapy or radiation therapy can have serious consequences, as both treatments are highly complex and require precise dosing and administration. Here is an example of each:
Example of Chemotherapy Error: Incorrect Dosage Calculation
Case:
A breast cancer Patient was prescribed medication as part of her chemotherapy regimen. The dosage was supposed to be calculated based on the Patient's body surface area. However, due to a clerical error, the Patient’s weight was entered incorrectly into the system, leading to a miscalculation of the body surface area. As a result, the Patient received a dose 50% higher than required.
Impact:
The Patient developed severe neutropenia (a dangerously low level of white blood cells), putting the Patient at risk for life threatening infections. Additionally, the Patient experienced significant nausea, vomiting, and fatigue, which could have been lessened if the correct dose had been administered. The treatment had to be paused for recovery, delaying the overall cancer treatment.
Cause:
a) Human error in entering the patient’s weight into the electronic medical record.
b) Lack of double checking by pharmacy staff or oncologist before administration.
Prevention:
Implementing a system where at least two healthcare professionals independently verify weight and dosage calculations.
Incorporating computerised alerts for significant dose variations from standard protocols.
Example of Radiation Therapy Error: Targeting Mistake
Case:
A Patient with prostate cancer was undergoing external beam radiation therapy. Due to a misalignment of the radiation machine (linear accelerator) during a treatment session, the radiation beams were not properly targeted. Instead of focusing on the prostate, the radiation was mistakenly directed towards surrounding healthy tissue, including part of the rectum.
Impact:
The Patient developed radiation proctitis, an inflammation of the rectal lining, which caused severe pain, bleeding, and bowel movement issues. Additionally, the therapeutic radiation dose to the cancerous prostate was suboptimal, potentially reducing the treatment's effectiveness.
Cause:
a) Equipment miscalibration or human mistake in setting up the radiation machine.
b) Inadequate verification of Patient positioning before delivering radiation.
Prevention:
a) Implementing stricter protocols for machine calibration and alignment.
b) Using image guided radiation therapy (IGRT) to verify tumour position before each treatment.
c) Increasing staff training on safety checks and the use of redundant systems to detect misalignments.
For more detailed insights into how the Patient Safety Act 2023 impacts you and how Whelan Law can support you, please visit our Patient Safety Rights Legal Advice https://www.whelanlaw.ie/news/medical-negligence-and-patient-safety/