Patient dies from Intrathecal Vincristine

[gwenith, BSN, RN]

Australian Broadcasting Corporation

TV PROGRAM TRANSCRIPT

LOCATION: http://www.abc.net.au/7.30/content/2004/s1102214.htm

Broadcast: 05/05/2004

Hospital mistakes

Reporter:

KERRY O'BRIEN: Medical errors in Australian hospitals have left a long trail of heartbreak and recrimination.

Two weeks ago, this program detailed a breakdown in procedure at Sydney's St George Hospital which resulted in a pair of surgical scissors being left inside a patient's abdomen for 18 months.

Tonight we reveal more evidence of procedural failure at St George Hospital which, in this case, resulted in death.

A routine round of chemotherapy treatment slowly paralysed a young cancer patient after an injection was wrongly administered.

The toxic drug eventually destroyed his nervous system, killing him.

One year on, the hospital's admitted its error. But where does that leave the victim's family?

Andrew Geoghegan reports.

TONY SQUILLACI: Obviously cancer's a big scare.

He was scared, he was shocked as well.

But his, you know, will to beat cancer was strong and we believe he would have beaten it should he have had the proper treatment.

ANDREW GEOGHEGAN: Diagnosed with cancer a year and a half ago, Guido Squillaci was devastated but optimistic.

The 28-year-old had developed Burkitts lymphoma, an aggressive disease which can respond well to chemotherapy.

ANGELA SQUILLACI: They said to me, "It's amazing the way he was and the way he is now. It all was clearing."

He say, "Mum, I want to live," so it was hard, but he did, until the last week when they made a mistake.

ANDREW GEOGHEGAN: A mistake which would cost Guido Squillaci his life.

Here at Sydney's St George Hospital, a series of errors culminated in his slow and painful death.

By the time the hospital had detected the mistake, it was too late.

DR DEREK GLENN, DIRECTOR OF RADIOLOGY, ST GEORGE HOSPITAL: This is, without doubt, a tragedy of a sort which we wish did not happen.

It's been intensely distressing to Guido's family and very distressing to the hospital staff.

ANDREW GEOGHEGAN: Guido Squillaci's cancer treatment involved regular chemotherapy using the drugs methotrexate and vincristine.

Methotrexate was injected into his spine by the radiology department, while separately, in the oncology ward, vincristine was injected into a vein in his arm.

TONY SQUILLACI: After the treatment he'd have to lie down for about four hours, flat.

After that, he could get up and he would walk, he'd go outside.

ANDREW GEOGHEGAN: For his last round of chemotherapy, Guido Squillaci was taken to the radiology department for his spinal injection of methotrexate.

He arrived without the drug and the radiology registrar rang the oncology ward to have it sent down.

But both methotrexate and vincristine were delivered to radiology.

Vincristine is a neurotoxin and its manufacturer specifically warns that injecting the drug into the spine, or intrathecally, is fatal.

TONY SQUILLACI: Guido said to me, "I feel different. This thing here, I think they've done something wrong."

I said, "Why?"

He goes, "My legs are sore."

He was in a lot of pain.

He told the nurses and doctors that day and they gave him just some painkillers.

ANDREW GEOGHEGAN: Guido Squillaci's clinical record instructs that he be given vincristine intravenously or into a vein and that on the same day he be given methotrexate intrathecally, abbreviated as 'IT'.

But the radiology department's procedure report, signed off by the registrar, provides damning evidence that procedure was not followed.

He wrote: "Vincristine and Methotrexate given intrathecally as requested."

Both drug labels had been placed on the report.

Printed on the vincristine label was the incomplete warning: "Fatal if give -- ".

It should have read: "Fatal if given intrathecally."

DR DEREK GLENN: The thing he didn't recognise was that administration of vincristine into the thecal space results in a fatality.

ANDREW GEOGHEGAN (TO DR DEREK GLENN): But he didn't read the warning label and he didn't follow the clinical instructions?

DR DEREK GLENN: The warning on that sticker is, in fact, incompletely printed, but it's nonetheless there.

But the type is about 2mm high, and we're in a darkened room - that's how it happened.

Staff in radiology should have checked the route, i.e. the way in which the stuff is to be given.

ANDREW GEOGHEGAN: Guido Squillaci had, in effect, been given a fatal spine injection, yet no one noticed.

The following day he complained of pain to hospital staff.

TONY SQUILLACI: And he had a bit of a fever.

He had the sweats, so Dad and I got him out of bed.

So we got his arms over our neck and we lifted him up.

He couldn't walk.

He couldn't help himself.

All he could do was hold up with his arms.

He was pretty much a cripple from the waist down.

ANDREW GEOGHEGAN: Tony Squillaci says the hospital told him that his brother could have a spinal infection.

However, subsequent tests proved inconclusive.

But by the Friday, the fifth day, Guido Squillaci had been complaining of pain and paralysis.

His treating specialist revealed that something was wrong.

TONY SQUILLACI: Guido at this stage was very, very angry and he swore at him.

He said, "I told your doctors and I told all your nurses that I was in pain on the Monday, on the Tuesday, on the Wednesday, on the Thursday, and you finally decide to show up today.

Why's it taken you so long?"

ANDREW GEOGHEGAN: It had taken St George Hospital staff a full working week to check Guido Squillaci's clinical record.

Only then did they realise they'd made a terrible mistake.

DR DEREK GLENN: And people don't go back and review notes routinely in the course of ongoing patient management.

TONY SQUILLACI: They saw on the notes that he was given two injections, both in the spine. Not one in the arm and one in spine.

We asked the doctor, "What does that mean?"

He said, "Vincristine was put into his spine and that should never go there - it's dangerous and he could die, and that's what's causing your brother's pain."

The vincristine was pretty much destroying his nervous system.

ANDREW GEOGHEGAN (TO DR DEREK GLENN): If a radiologist is not familiar with a drug shouldn't he go on the side of caution?

DR DEREK GLENN: Yes, I agree, but you - I mean, to an extent that's true, but the question is, again, I guess it comes back to knowing what this is.

What level of knowledge of vincristine is expected of a radiology registrar?

This is an extraordinarily rare event.

It's documented - if you look it up and you go chasing for it, you can find references to it, you can find incidents, and they're surprisingly similar, but it is nonetheless an extraordinarily rare event happen.

ANDREW GEOGHEGAN (TO DR DEREK GLENN): Were they wary that a problem like this could occur?

Was anyone at the hospital wary of that?

DR DEREK GLENN: We're always wary of problems of incorrect administration of medication - I mean, that's a given.

Was the hospital aware that specifically this particular error is a live possibility and could happen?

Not explicitly.

ANDREW GEOGHEGAN: But by St George Hospital's own admission, the delay in identifying the error would severely limit Guido Squillaci's chances of survival.

The clinical notes reveal: "The interval between the incident and detection is long in comparison with the literature case reports that were associated with survival."

Despite this, the hospital attempted to stop the toxic effects of the drug spreading through his body.

Guido Squillaci was subjected to the highly risky procedure of having his spinal fluid drained.

TONY SQUILLACI: It was scary seeing him in intensive care again.

He had all these pipes and machines off him.

He had his head bandaged and he had a drip at one end of the bed and a drip at the other end of the bed where you could see his spinal fluid coming out...

ANGELA SQUILLACI: The other one going in.

TONY SQUILLACI: ...and you could see this man made substance going in.

ANDREW GEOGHEGAN: Guido Squillaci survived the operation but as each day passed his paralysis worsened.

TONY SQUILLACI: The doctors would come and do tests every day, where they'd get pins and they'd prick him on various parts of the body to see how far the damage has gone.

So by the end of 28 days he was pretty much paralysed all over, bar he could still understand, he could still talk and he could still breathe. But he couldn't move any part of his body, not even his head.

We called the chaplain and the priest came and said, "Bless you, Guido," and Guido said, "No, say a prayer, I'm not dying."

DOMENICO SQUILLACI: He say, "Mumma here, Tony's here", I hold his hands like this.

He say, "Dad's here."

ANDREW GEOGHEGAN: In April last year, Guido Squillaci succumbed to the toxic effects of vincristine, which had destroyed his nervous system.

The autopsy report found: "...the cause of death was believed to be the consequences of the treatment of Burkitts lymphoma, particularly the inappropriate administration of intrathecal vincristine."

The coroner has yet to release a finding on Guido Squillaci's death while the NSW Health Care Complaints Commission is also investigating.

St George Hospital, meanwhile, has changed its protocols to ensure the same tragic chain of events never occurs again.

DR DEREK GLENN: We've changed the way the drug is prepared.

They're made up in different volumes.

The intravenous dose is made up in a much larger volume.

That was advice - a trick, if you like - that we picked up from the UK experience, where they adopted that change.

We've changed the timings.

The intrathecal dose and intravenous dose are not prepared at the same time now.

ANDREW GEOGHEGAN: Staff caught up in the chain of errors have been reeducated.

As for the doctor who injected the neurotoxin...

DR DEREK GLENN: He considered resigning.

I dissuaded him from that course.

I don't know whether he considered any more drastic personal actions like that, but there isn't a day goes by that he doesn't consider it, and it's changed his personality.

He's less carefree and happy than he was.

ANDREW GEOGHEGAN: If having to deal with their loss is not enough, the Squillacis could lose financially as well if they seek compensation.

KAREN STOTT, SOLICITOR: The family could even end up owing the defendant money due to restrictions on the recovery of legal costs from the other side and also having to establish 15 per cent of a worst case scenario injury for nervous shock for the extent of the grieving by the family members.

If they can't establish that, their case is worth nothing.

ANDREW GEOGHEGAN: Karen Stott, the Squillacis' solicitor, cites a 1995 case where a Victorian man received $6 million from Geelong Hospital after the same mistake left him totally paralysed.

But as Guido Squillaci had no dependents, his family must prove they've suffered nervous shock.

KAREN STOTT: From a monetary point of view when you're talking about a compensation claim, it's better that he died from the hospital's point of view.

Tort law reform does have a lot to answer for because in this particular case it's pretty much made the difference between a family who have a cause of action suing and now I don't think they will sue.

So that should comfort the doctors and the hospitals quite nicely, and the insurance companies.

ANGELA SQUILLACI: I can't fight, because I lose my house.

The system is wrong.

If my son was alive, I would go to the end of the world, I would sell everything, but for what?

My son is not here.

He no come back.

DOMENICO SQUILLACI: I have no peace, no peace, 'cause he taken from my hands like this.

KERRY O'BRIEN: That report from Andrew Geoghegan

[caroladybelle, BSN, RN]

I am in shock that anyone would inject a vesicant in other than a IVAD. We require so many checks that it is unreal.

I would have thought that the injection would have hurt too much to be tolerable and I am also surprised that it took so long for him to die.

[canoehead, BSN, RN]

That happened at a hospital I used to work at. A 4th year resident in the PICU injected Vincristine in to the spine of a 6yo who died a week later. Policy was changed so no matter where an oncology patient is the oncology nurses come down off the floor to do chemotherapy, or the attending physician can do it. The doc that did it was very concientious, and caring, but picked the wrong moment to put his guard down. Rumor was that he just did what he was told to do by a more experienced person, but you could see the pain on his face even a month later.

I can never say a mistake is too stupid for me to make- I've made some bad ones. There but for the grace of God goes every one of us.

[Rapheal]

Well said Canoehead. We all make mistakes- and pray they are not big ones.

[moia]

strangely....I have absolutely no sympathy for anyone who makes the vincristine error because it was an issue on just about every evening "news" program in the US and Canada about five years ago.

Everyone in pharmacy should have been completely aware and that vincristine should never have been released at the same time as the methotrexate.

Even worse the resident who gave it broke EVERY rule in medication administration...he obviously had NO idea what the drug was or what it did....I have no sympathy with anyone who is incapable of saying HELP what do I do with this?....it's completely unaccesptable in this day amd age when a resident has no limits in accessing quick and easy information...he could have called pharmacy, he could have looked it up on the internet, he could have spend two minutes reading the instructions on the package.

That docs ego killed the patient..he was too proud to ask for help in administering a drug he was completely unfamiliar with.

There is nothing wrong with saying I don't know...those simple little words have saved lives every day.

[gwenith, BSN, RN]

Here is part 2 of that story - Moia one of the reasons why they were not as aware of the dangers of Vincristine is that it was not well reported here in Australia until this latest case.

Australian Broadcasting Corporation

TV PROGRAM TRANSCRIPT

LOCATION: http://www.abc.net.au/7.30/content/2004/s1103103.htm

Broadcast: 06/05/2004

Pharmacologist warns hospitals to take care

Reporter:

KERRY O'BRIEN: Last night we brought you the story of a young cancer patient that destroyed his nervous system.

The hospital is now assuring its patients that it has changed its protocols for administering chemotherapy drugs.

But a leading Australian pharmacologist warns that the same fatal error will continue to occur unless Australian hospitals adopt a very simple method of administering anti-cancer drugs.

Andrew Geoghegan reports.

MICHAEL DOOLEY, DIRECTOR OF PHARMACY, PETER MACCALLUM CENTRE: It is understandable to the degree that human error does occur.

What isn't understandable is that this is a well known problem.

This drug has been available for 40 years.

These events have been occurring for decades.

These events should not happen.

ANDREW GEOGHEGAN: Mistakenly injecting the powerful anti-cancer drug vincristine into a patient's spine is a fatal medical error, which has been well documented around the world.

But as the 7:30 Report revealed last night, that hasn't stopped the same fatal mistake from happening in Australian hospitals.

TONY SQUILLACI: They saw on the notes that he was given two injections both in the spine.

Not one in the arm and one in the spine.

We asked the doctor, "What does that mean?"

He said vincristine was put into his spine and that should never go there, it's dangerous and he could die and that's what's causing your brother's pain.

ANDREW GEOGHEGAN: Twenty-eight-year-old Guido Squillaci died in April last year after medical staff at Sydney's St George Hospital mistakenly injected the neurotoxin vincristine into his spine instead of a vein in his arm.

What should have been a routine round of chemotherapy ended up destroying his nervous system, slowly paralysing him to the point of death.

ANGELA SQUILLICA: I said, "Do you want a new life or you want to be dead?"

He said, "I want to live," so it was hard but he did until the last week when they made a mistake.

MICHAEL DOOLEY: This particular mistake of giving vincristine into the spine with a fatal occurrence can be prevented.

ANDREW GEOGHEGAN: Michael Dooley is the director of pharmacy at Melbourne's Peter McCallum Cancer Centre, Australia's only specialist cancer hospital.

He's made a submission to the Australian Council of Safety and Quality in Health Care for the introduction of a standard procedure for administering vincristine.

MICHAEL DOOLEY: And until there are changes in the practices of how the drug is administered and as long it continues to get administered in a syringe, it is only a matter of time before another fatal event occurs.

ANDREW GEOGHEGAN: The senior lecturer in pharmacy and oncology at Monash University has devised a fail safe system for administering vincristine which some hospitals have adopted.

MICHAEL DOOLEY: The problem we have is that we have two drugs to give - one to go into the spine and one to go into the blood.

The problem is when the one that's supposed to go into the blood gets injected into the spine and often when that does occur it's almost always fatal.

A simple way around that is to have the one that needs to go into the blood into a bag so it cannot get injected into the spine.

ANDREW GEOGHEGAN: St George Hospital has made changes to its chemotherapy protocols, which it claims will prevent a repeat of the fatal error.

DR DEREK GLENN, DIRECTOR OF RADIOLOGY, ST GEORGE HOSPITAL: We've changed the way the drug's prepared.

They're made up in different volumes.

The intravenous dose is made up in a much larger volume.

That was a trick that we picked up from the UK.

ANDREW GEOGHEGAN: But it still took the death of Guido Squillaci for St George Hospital to move to a safer system, despite 14 reported similar cases in the UK.

In a well publicised incident three years ago, 18-year-old Wayne Jowett, who was in remission from leukaemia, died after Dr Feda Mulhem mistakenly ordered a spinal injection of vincristine.

An independent investigation later highlighted design faults in the drug packaging and the syringes used to administer the vincristine.

MICHAEL DOOLEY: Certainly there would be many hospitals that are doing it in a syringe, which leaves the possibility of it inadvertently being administered into the spine, with fatal occurrences.

ANDREW GEOGHEGAN: The latest fatality in the UK saw Dr Mulhem sentenced to eight months jail.

Staff involved in the fatal mix-up at St George Hospital remain on the job while the coroner considers the case.

[renerian, BSN, RN]

It is to bad that vincristine checking passed through so many safety points.

renerian

[KMSRN]

Here is part 2 of that story - Moia one of the reasons why they were not as aware of the dangers of Vincristine is that it was not well reported here in Australia until this latest case.

Physicians and nurses shouldn't be relying on the news media for their drug knowledge. No one should be giving a drug unless they know what it is and how it is supposed to be given. Unfortunately we are all human and capable of making mistakes - I'm sure everyone involved is devatated.

[nightingale, RN]

How devastating one decision, one routine procedure, a moment in time can make anothers life. Above all, we are to cause no harm.

I do empathize with the family and for the patient's pain, suffering and loss; I also empathize for the doctor and staff.

Well said Canoe: There but for the grace of God goes every one of us.

night

[moia]

But it's not there but for the grace of God........it was an idiots mistake....we all have had moments when we couldn't reminder a drug...we ask someone or look it up or look at the MAR...I have never ever said oh well I"ll just push this into your spine cause thats what I did with that other drug. I don't think there is a nurse practicing that has ever not bothered to educate themselves about a CHEMO drug...because nurses can't give these drugs without special training. This is why nurses have special rules about who and where they can give IV drugs.

It's not a mistake at all...there was no error...it was a WILLFUL disregard for the patient safety...this doctor made a decision to inject a drug he had absolutely no knowledge of...this cannot be considered a med error because ANYONE who knew what vincristine does would NEVER inject it into the spine. A med error with vincristine is injecting it without getting a blood return on your IV. A med error would be injecting it into an interstitial IV...or not properly diluting the med....

YOu can't give ANY drug to a patient that you have no education about...this includes EVERY drug.

I don't believe the many nurses that have mistakenly injected potassium are med errors either. If you follow some very basic rules like look at the drug container and label your syringes you can avoid this..

A true nurse med error is pharmacy makes an error and the drug is given to the patient. or a late or early dose or a missed dose or the doctor made an error..that's a mistake...anything else is willful negligence. Doctors must have as many safety rules in place as nursing.

What makes me insane about this is vincristine comes with directions and a ton of warnings...yes it is small print but if you are a doctor who hasn't got a clue about the drug you are about to give all you have to do is read the package insert.

This isn't a med error and personally I think that doc needs his license revoked and criminal charges applied...there is absolutely no excuse for giving someone medication you didn't bother to educate yourself about.

I think eight months in jail is a pretty sad thing when this fools ego killed someone.

I wish I could have everyone in hospital wearing a tshirt that sayss "when I don't know I ask"...what is soooo hard about this?

If a drug is unfamiliar look it up..find out what it does and how it should be given and what side effects you should be watching for..that is your job.

[psychomachia]

But it's not there but for the grace of God........it was an idiots mistake....

I think you should save your criticism of an event that you were not present for and try to understand the term "system failure" as opposed to your "guilty on all counts" judgment of the person involved. Yes, we all have a responsibility to know the 5 rights, but serious errors are rarely an individual event.

from above:

Methotrexate was injected into his spine by the radiology department, while separately, in the oncology ward, vincristine was injected into a vein in his arm.

However, this time a mistake was made:

He arrived without the drug and the radiology registrar rang the oncology ward to have it sent down.

But both methotrexate and vincristine were delivered to radiology.

Who sent both meds to radiology?? When "normally" the vincristine would have been administered on the oncology unit??

And yet another mistake:

Printed on the vincristine label was the incomplete warning: "Fatal if give -- ".

It should have read: "Fatal if given intrathecally."

Now before you accuse me of not understand an individual's responsibility to the pt., you have to admit that the label was not printed properly - another example of how a "system" is supposed to be in place to make the chances of an error less, not more.

Another item to consider:

But the type is about 2mm high, and we're in a darkened room - that's how it happened.

Staff in radiology should have checked the route, i.e. the way in which the stuff is to be given.

Once again, I'm not absolving the individual, but when you work in an environment that makes it difficult to do your job, then the "system" is partially at fault for placing the individual in the situation - 2mm type in a dark room should not be considered ideal, should it?? And was there more than one MD or RN present?? Or did the system fail becuase an individual was expected to administer chemo without a medication check?? If insulin is so dangerous we need two nurses to agree, I sure as hell think chemo would be too?? Once again, a system failure as opposed to an individual failure.

One more thing to consider:

It had taken St George Hospital staff a full working week to check Guido Squillaci's clinical record.

Many mistakes happen and if caught early, are treated / observed and little damage is done. That doesn't excuse the mistake, but indicates the system's ability to control the damage. Here the system failed to identify the mistake and the outcome was worse than it should have been.

How many mistakes were made with lasix and K sitting next to each other in the same colored/sized bottle?? Why are so many meds "color" coded to avoid errors. Why do we do insulin checks?? Why do we write "units" instead of "U"??? Becuase NOBODY is perfect and mistakes will be made - some are much worse than many others, but if you look closely you'll see that often it is a system of errors and rarely is it entirely an individual error.

I'm not a "believer" as many here know, but I think the saying applies...There but for the grace of God...

Hope someone doesn't judge you to harshly when you make your first mistake...

[psychomachia]

Australian Broadcasting Corporation

TV PROGRAM TRANSCRIPT

LOCATION: http://www.abc.net.au/7.30/content/2004/s1102214.htm

Broadcast: 05/05/2004

Hospital mistakes

Reporter:

Here is a link to a report from the NHS about intrathecal vincristine errors: http://www.dh.gov.uk/assetRoot/04/06/50/49/04065049.pdf