The family has asked that they not be identified by name as they grieve the loss of their family member lost to a massive overdose of the chemotherapy drug 5-fluorouracil. Last week, a 43-year-old mother of three, died from a massive chemotherapy drug overdose mistakenly administered by a portable pump used primarily by gastrointestinal, genito-urinary and head and neck cancer patients. The fatal dose of 5-fluorouracil was 24 times what was intended.
According to the report, a nurse programmed the wrong information into the woman’s pump. Another nurse checked the pump but failed to notice the error. Four days later, the woman was dead. The Cross Cancer Institute calls this mistake one of the center’s worst nightmares but they will not hide the mistake.
While the nurses who made the error are receiving counseling over the mistake they made that led to the mother’s death, they will not be disciplined for the error, as the cancer center believes it was not due to negligence. Then what was it due to? There are times when human error cannot be allowed to be made as it can be fatal — as in this case. There are some professions that require an absolute fail-safe set of procedures and practices that do not allow for human error. A standard of professional excellence in carrying out one’s job that this type of incident does not happen — even once. Because human life can be lost. How do you remedy that error — right that wrong? I feel for this family, for the children left motherless due to the errors made by two nurses.
According to the woman’s oncologist, she had a 75 percent chance of surviving her cancer diagnosis. Tragically, she did not survive treatment. An investigation by the Institute for Safe Medication Practices is underway, and the cancer center states it will implement any changes recommended.
Source: The Cancer Blog
