ABSTRACT
In March 2013, it was revealed that cancer patients in two Canadian provinces (mostly Ontario, though with one case in New Brunswick), had received incorrect dosages of their chemotherapy medications (Ziomislic and Alamenciak, 2013). In total, 1,202 patients were affected, from February 2012, through to March 2013. The mistake was caught when a pharmacy assistant noticed something strange about the bags of gemcitabine-they required refrigeration, which previous bags had not. Their labels were also different and were missing key pieces of information required to mix the medications properly. He brought it to the attention of the supervising pharmacist, who in turn reported it to others. What they found was that the bags of chemotherapy medication were significantly diluted-by as much as 20 percent-and that, as such, patients had received dosages much lower than they had been prescribed. The incident has been called “the worst chemotherapy mistake in Ontario’s history” (Ziomislic and Alamenciak, 2013).
