Drug Dosage Issue

LHSC statement regarding the Standing Committee on Social Policy report on Diluted Chemotherapy Drugs:

LHSC fully supports any reviews conducted to ensure system safeguards are in place that prevent a recurrence of this issue. Similar to the Theissen report, the Standing Committee's report released late yesterday highlights breakdowns in the system and also recommends further actions across several stakeholders to strengthen treatment safeguards.

From a hospital perspective, we have the fullest confidence in our pharmacy and cancer teams. Everyone's goal in this is to ensure safety and quality and to restore patient confidence in their health system. Last year, LHSC implemented process changes to safeguard against any similar incident occurring and we will continue to support any further reviews that may be conducted surrounding the chemotherapy dosage issue.

Murray Glendining
Acting President and CEO
London Health Sciences Centre

Dr. Thiessen’s independent review of quality assurance in the province's cancer drug supply chain

In April 2013, the Ontario government appointed Dr. Jake Thiessen, the Founding Director of the University of Waterloo’s School of Pharmacy, to lead an independent review of the recent discovery of under-dosing of chemotherapy drugs at five hospitals in Ontario and New Brunswick.

London Health Sciences Centre welcomes this report, and we thank Dr. Thiessen for his thorough review, thoughtful analysis of the issue and his insightful recommendations.

We believe that his recommendations will serve our patients well.

London Health Sciences Centre will work closely with the Ministry of Health and Long-Term Care (MOHLTC), Ontario College of Pharmacists (OCP), Group Purchasing Organizations, the Ontario Hospital Association (OHA) and other affected hospitals to implement Dr. Thiessen’s recommendations.

Although there were no recommendations specific to London Health Sciences Centre, we play an important role in moving many of the recommendations forward.

This has been a difficult and challenging time for our patients and their families. We will be sharing this report with our Cancer Patient and Family Advisory Committee and keeping our patients and our advisory committee updated on changes and enhancements made as a result of the recommendations.

Dr. Thiessen’s report can be viewed here: http://www.health.gov.on.ca/en/public/programs/cancer/drugsupply/docs/report_thiessen_oncology_under-dosing.pdf

Chemotherapy Patient Update - May 2013

April 2013 Update

London Health Sciences Centre has been advised of an issue affecting the concentration of two drugs used in patient treatment plans. Cyclophosphamide and Gemcitabine were prepared by a drug supplier and provided to London Health Sciences Centre between March 1, 2012 and March 22, 2013.

Upon learning of the issue, LHSC took immediate steps to remove all products from this supplier and began to prepare the medications in our own hospital pharmacy. No patient treatment cycles have or will be interrupted during this transition. LHSC also immediately began a review of records to identify impacted patients. LHSC is also working with Cancer Care Ontario to address this issue.

Although this issue resulted in a reduced dose of medications in treatment, the probability that this single factor alone has had an overall serious effect is small. However, it is not possible to determine if this issue is completely without risk. The health of our patients is our first priority. We are investigating this matter internally and with external partners to establish root cause and to prevent future occurrences.

The Ministry of Health indicated that an independent expert panel led by Dr. Thiessen would be assembled to review quality assurance, reaching out to hospital leaders, Cancer Care Ontario, the College of Pharmacists, and Health Canada to bring together the right group to take a close look at how best to safeguard patient care to prevent incidents like this. LHSC is fully supportive of this approach and will actively contribute to the review.

Standing Committee on Social Policy:

Information from the Government of Ontario:

LHSC media statements

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