MOH alerts hospitals after two women given wrong dosage
of cancer drugs
SINGAPORE: The Ministry of Health has alerted all
hospitals to take immediate measures to ensure safety in the use of
infusion pumps when administering drugs.
This follows a pharmaceutical error at KK Women's and
Children's Hospital - where two cancer patients are now under
observation, with one potentially in grave danger.
Mrs L K Ng, aged 51, and Mrs Yip Poh Hung, aged 44, were given
chemotherapy drugs via an infusion pump - but settings on the pumps
were inaccurate, despite two pharmacists checking to ensure
accuracy before the infusion pumps were given to the women.
The ministry said it will share the findings and risk reduction
strategies with other hospitals after KK Hospital completes its
detailed root cause analysis.
If things go wrong, Mrs Yip Poh Hung's organs could be damaged
seriously. She is being given an antidote – Vistonuridine -
specially flown in from the US. Although stable at the moment, she
still needs to be observed carefully. She had consumed five days
worth of cancer drugs in just five hours.
The hospital said the antidote being given to the patient is safe
to use, even though the drug has not been approved for general use
in Singapore. The drug has not even been approved by the FDA in the
US. But the hospital is citing a recent study to vouch for its
safety.
"They have tested this drug and out of the 17 patients, all
actually recovered well. So that is why it is important to have
this particular drug for our patient here," said Associate
Professor Tan Kok Hian, director, Clinical Quality, KK Women's
& Children's Hospital.
The hospital said her chances of full recovery are "very
high".
Singapore's Health Sciences Authority (HSA), which gave the last
minute green light for the special use of the antidote in this
instance, said: "Our regulatory framework has a system in place
that allows HSA to consider special concession for clinicians to
use unregistered medicinal products under exceptional medical
circumstances, when there is no registered alternative available in
Singapore.
"This is to ensure that patients are not denied access to critical
treatments in the case of unmet medical needs." The HSA added that
there have been past approvals granted in life or death situations
where no alternative is available in Singapore.
Meanwhile, the pharmacists in question have been assigned "light
duties", while they assist in investigations.
Hospital officials said they have apologised to the patients and
their families. The hospital is also waiving current medical fees
for the next cycle of chemotherapy treatment. As for further
compensation, the hospital said the issue has not surfaced.
As a safeguard, the hospital has now decided to use only one type
of infusion pump, so that the rate and calibration will be clearer
and chances of error will be further diminished.
"We have a variety of pumps - the default rate is set at one rate
and another pump is set at another rate. So sometimes if you are
using the different pumps you should know the default rate and to
set it accordingly. Unfortunately, it is very rare, there was an
error and it wasn't recognised," said Prof Tan.
"KK is also sorry about this incident and we take full
responsibility for this error and we would also like to say sorry
to the patients and their families who are involved," added Prof
Tan.
Some patients, the hospital said, were concerned about their own
medication after learning about the incident. However, doctors said
the patients' fears were assuaged and they were informed that the
chances of such errors are extremely rare.
The hospital said investigations are ongoing.
- CNA/sc
