Chemo drug scandal: Pharmacy assistant that uncovered error says ‘It’s just part of our job’

The curiosity of a soft-spoken 28-year-old pharmacy assistant in Peterborough uncovered the medication error that went undetected at four other hospitals and saw more than 1,200 cancer patients receive diluted chemotherapy cocktails over the past year.

Craig Woudsma noticed that bags of intravenous medication from Marchese Hospital Solutions, a new supplier to the Peterborough Regional Health Centre, had to be refrigerated, while those from the old supplier did not.

It was enough to give Woudsma a feeling something was amiss.

He compared the two labels and noticed the Marchese one had less information on it, and that the numbers didnt match the electronic worksheet with the patients individualized chemotherapy recipe.

It just raised questions and, at any point during a process like this, you dont want to have questions, said Woudsma, testifying at a Queens Park social policy committee meeting where the diluted chemotherapy scandal is being investigated.

A total of 1,205 Canadian cancer patients received diluted doses of chemotherapy medication over the past year. One-hundred-and-fifty patients have died since the diluted treatment began to be administered in February 2012. Its unclear what, if any, role the diluted medication played in their deaths.

Hospitals have said Marchese supplied diluted bags of chemotherapy medications gemcitabine and cyclophosphamide. Marchese maintained it provided the cancer drugs in compliance with a contract with Medbuy, a group purchasing company for hospitals. Officials from Medbuy told the committee Monday that Marchese did not fulfill its contract, and that the supplied products didnt match the labels.

A Toronto Star investigation last month revealed that Marchese Hospital Solutions was part of a growing industry of companies operating without federal or provincial oversight while supplying mixed drugs to hospitals. While government policing applies to drug manufacturers and pharmacies, triggering regular inspections and compliance with quality assurance rules, no such protocols exist for companies like Marchese Hospital Solutions.

Labels on the medication bags supplied by Baxter, who provided the drugs before Marchese, indicated the concentration of drug per milliliter of liquid. Marcheses labels show the total amount of medication and volume of saline in this case, 4 grams of gemcitabine in 100 millilitres of saline. The bags do not indicate overfill.

Hospitals have testified they had up to 20 per cent more saline than indicated, diluting individual doses of drugs.

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Chemo drug scandal: Pharmacy assistant that uncovered error says ‘It’s just part of our job’