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Inquiry finds multiple failures in SA chemo bungle


A failure to follow routine clinical processes and procedures has been blamed for 10 South Australian cancer patients receiving incorrect chemotherapy treatment.

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Health Minister Jack Snelling has released the results of an inquiry into the bungle and says it also found staff at the Royal Adelaide Hospital and the Flinders Medical Centre failed to disclose the mistakes to patients or management.

Snelling says staff are being talked to and other actions have been taken to prevent similar mistakes in the future.

The bungled cases, between July 2014 and January this year, involved patients being underdosed because of a typographical error.

“Following an extensive review, the panel has found that the under-dosing was caused by a series of significant clinical governance failures at the Royal Adelaide Hospital Haematology unit,” Snelling said.

The inquiry also found a similar typographical error involving the protocol for treating patients with aggressive lymphomas.

That error had potentially impacted on nine patients between 2005 and 2015 but found only one had received a lower-than-recommended dose of prednisolone.

Snelling said that person was now in remission but had been given an opportunity to talk with a doctor in relation to any ongoing concerns.


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