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BBC News Online: Health


Wednesday, 24 January, 2001, 12:14 GMT

Ministers miss drug blunder deadline


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Ministers missed a deadline urged by their own taskforce to eradicate the type of drug blunder which has left a teenager close to death.

The 19-year-old, who was being treated for leukaemia at Queen's Medical Centre in Nottingham, was given an injection of the powerful cancer drug vincristine into his spine instead of a vein.

Experts say this is likely to prove lethal, possibly within days, but perhaps weeks or even months later.



There really isn't any central reporting procedure so you can look back and see what went wrong.
Dr Kate Law, Cancer Research Campaign

And it has been revealed that exactly the same mistake has led to at least a dozen deaths over the past 15 years.

The Department of Health set up a committee - chaired by Chief Medical Officer Professor Liam Donaldson - to come up with ways of reducing the number of medical mistakes within the NHS.

Its report in June 2000 urged the government to examine ways of completely wiping out deaths and disability caused by "wrongly administered spinal injections" by the year 2001.

The vincristine injection which is likely to kill the Nottinghamshire teenager was given just four days after that deadline was passed.

The department told BBC News Online that no method for eradicating this problem had been discovered, and that this was unlikely before the end of this year.

Pragmatic solution

It said that the only "pragmatic" solution was to put back the deadline for wiping out deaths.

The department also pledged in June to bring in a new mandatory reporting system for logging all errors of this type, and even "near-misses" where no substantial harm was caused.

They said this would be "in place before the end of the year", but now say that it will be at least the end of 2001 before such a system can be introduced.

Professor Donaldson is awaiting the results of an internal inquiry at Queen's Medical Centre before deciding whether or not to carry out his own investigation.



The aim is to ensure that no more patients die or are paralysed. New protective measures are due to be in place before the end of the year
Department of Health spokesman

Two doctors connected with the case have already been suspended pending the results of the inquiry.

A Department of Health spokesman: "The complex problem of maladministered spinal injections is one of the issues being targeted during the implementation of a new plan to identify, learn from and reduce risk from medical error and adverse events in the NHS.

"The aim is to ensure that no more patients die or are paralysed.

"New protective measures are due to be in place before the end of the year."

Cancer experts are still incredulous that cases such as these still arise.

Terribly depressing

Dr Kate Law, from the Cancer Research Campaign, told BBC Radio 4's Today programme that it was "terribly depressing" that the lethal vincristine error is repeated so often.

She said: "There really isn't any central reporting procedure so you can look back and see what went wrong. I would think there have been dozens of cases.

"It's a very toxic drug, which even if given into a vein can cause severe neurological problems unless care is taken.

"It's not fair that this job is delegated to doctors who are not experienced in the administration of this drug."

Professor Denis Smith, a member of the Chief Medical Officer's Committee, told BBC News Online: "I actually think that a target of zero fatalities is an important one - quite clearly there are no levels of acceptable fatalities here.

"Whether it is an achievable target without making quite fundamental changes to the way in which some individuals and organisations work is a different matter."

The vincristine error is thought to happen because another leukaemia drug, methotrexate, is usually given by injection into the spine.

However, there are clear warnings on both the packaging and phial that spinal injection of vincristine will be fatal.

Queen's Medical Centre has already apologised to the parents of the 19-year-old, who has not been named.


Related to this story:
'Cancer drug mistake killed my child' (24 Jan 01 | Health) Inquiry into cancer drug tragedy (24 Jan 01 | Health) Leukaemias and lymphomas (17 Mar 00 | C-D) What is chemotherapy? (17 Mar 00 | C-D)


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