A chemotherapy bungle that led to the under-dosing of patients with acute myeloid leukaemia was the result of a “disturbing and indefensible failure” in clinical governance, a damning report into the incident says.

Ten leukaemia patients treated at the Royal Adelaide Hospital were given incorrect doses of cytarabine over a six-month period between 2014 and 2015.

The error was uncovered by a pharmacist from the RAH who contacted the Deputy Director, Haematology and Bone Marrow Transplant Service, who confirmed that the correct dose was twice daily and not once daily.

The doctor confirmed that the protocol was wrong and acted to have it amended.

However, a group email “which did little to highlight the error” was sent to cancer clinicians alerting them to the incorrect treatment protocol went unnoticed by the clinicians at Flinders Medical Centre who were also treating patients under the protocol.

The report conceded that the email did not highlight that the reason for the amendment to the protocol was a previous error, and that the email could have been read as a routine change of procedure.

The review also found that staff at the Royal Adelaide Hospital had little or no knowledge of the Incident Management guidelines or how to make a safety incident report within the required timeframe.

“It is disturbing that senior clinicians were not aware of their professional responsibility to report the adverse event,” the report states.

“At the very least they should have made inquiries with the hospital management on how to discharge this responsibility” it said.

The review panel made six recommendations:

1. That Central Adelaide Local Health Network review its clinical governance framework, structure and procedures.
2. That the clinical and management staff who failed to comply with SA Health incident management and open disclosure policies complete as a matter of urgency training in these areas.
3. The SA Health draft Patient Incident Management and Open Disclosure Policy Directive and its tools and associated documents be finalised and implemented as a matter of urgency.
4. Implementation of the new clinical governance policies and tools be accompanied by a systematic and audited training program across all South Australian health services.
5. SA Health develop an understanding and appropriate protocols with SAICORP to ensure that the issue of compensation is included sensitively as part of the open disclosure process, and that South Australian health services have the capacity to make reasonable and timely without prejudice payments to patients suffering from the impact of health service errors.
6. The legislative provisions which operate to protect certain information from disclosure as currently applied to reports of the investigation, analysis and recommendations of incidents reported on the Safety Learning System should be reviewed.

SA Health interim Chief executive Vickie Kaminski said SA Health had accepted and begun to implement all of the recommendations.

A copy of the Australian Safety and Quality Commission’s report, and SA Health’s new Open Disclosure Policy, is available: Independent review of the incident notification, management and analysis of incorrect dosing of cytarabine.

Related story: Significant failures’ identified in Adelaide haematology unit