N.L. health staff slow on drug errors

Areview of drugtesting errors that potentially affected hundreds of patients in Newfoundland and Labrador found thatEastern Health Authority staff didn't react quickly enough when problemsadministering cyclosporine were first identified.

"Initial concerns were raised on Jan. 18, 2010, yet it was not determined until Feb. 12, 2010, that one of the analyzers was providing incorrect results," said an internalreport.

The reportalso concluded that Eastern Health leaders weren't notified about the problem quickly enough.

"The executive of Eastern Health was not advised in a timely manner of the testing errors," according to the report.

Last Friday, Eastern Health's CEO said she wasn't told that some patients were being given too much cyclosporine until Feb. 19 when a 14 year-old receiving theimmunosuppressivedrugwas admitted to intensive care.

Tuesday health authorityofficials saidthe teen is still in intensive care in St. John's.

Cyclosporine suppresses the immune system, and is used to prevent organ rejection in transplant patients and treat symptoms of autoimmune diseases like lupus and rheumatoid arthritis.

The report relesed Tuesday confirms that a machine Eastern Health bought last April to measure blood levels of cyclosporine was not calibrated correctly by health authority staff.

It's now believed that 212 patients may have received too much of the drug, which can cause kidney damage.

The report also says that staff did not report the errors properly.

"The filing of the occurrence report was not completed in a way that would conform to Eastern Health's occurrence reporting policy," said the report.

Eastern Health's CEO said that is not acceptable.

"We take it very seriously. We are not happy at all that we're in this position," Vickie Kaminski said Tuesday.

Kaminski saidthe lab didn't file an occurrence report when it knew there was a problem.

"The lab did not document an occurrence. They, they knew that they had this issue. They did not document an occurrence," she said.

A group from the University Health Network in Toronto is to begin a review of Eastern Health's laboratory services this week.

The review released Tuesdayrecommends that:

• The University Health Network review to begin with the biochemistry analyzer review questions.
• Laboratory and other clinical staff to be reminded to document all occurrences when they are reported, whether they are confirmed occurrences or near misses.
• Laboratory leadership to review the occurrence reporting policy at Eastern Health immediately.
• Occurrence reporting policy to be reviewed with all laboratory staff within the next two weeks.
• Reinforce occurrence reporting policy within Eastern Health through education Quality Round is to be organized in the Laboratory Medicine following completion of the internal review.
• A Quality Round is to be organized in the Laboratory Medicine following completion of the University Health Network review.