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Use of outdated measurements during chemotherapy treatment (14HDC01771)
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(14HDC01771, 28 June
District health board ~ Oncology ~ Chemotherapy treatment ~
Adverse comment ~ Right 4(1)
A 51-year-old woman was diagnosed with ovarian cancer. At that
time she weighed 84kg. She was seen by an oncologist at a district
health board (DHB1), and agreed to receive neo-adjuvant
chemotherapy with paclitaxel and carboplatin.
As the woman did not live in the DHB1 region, she travelled to
her nearest public hospital's (DHB2) oncology clinic chemotherapy
unit for her treatment. An oncologist from DHB1 attended twice a
The dose of carboplatin is based on an assessment of the level
of the patient's kidney function. DHB1 uses a computer based
calculator, the Aesculapius programme, which calculates the
carboplatin dose based on the patient's weight and serum creatinine
level. At the time of the woman's treatment, the chemotherapy staff
nurses documented the patient's height and weight only at the
initial visit, and did not note the weight again. When the patient
was seen in the oncology clinic, the oncologist noted the weight in
the clinical file but, as the Aesculapius programme was not readily
available to the consultant while at DHB2, the input into the
computer system depended on the oncologist entering the information
when he or she returned to DHB1.
The woman had one cycle of paclitaxel/carboplatin, which was
poorly tolerated. She underwent a total abdominal hysterectomy and
bilateral salpingo- oophorectomy. The surgery was uneventful.
Five months later the woman's weight was 70.8kg. The oncologist
planned to resume chemotherapy. A CT scan was performed, which
showed no evidence of disease, and the woman then declined further
chemotherapy. It was decided to monitor her progress and not
administer further chemotherapy at that time. Four months later the
woman's weight was 72.9kg. She had a CT scan, which showed further
progression of the disease. The woman was treated with oral
A year later, the woman's weight was 65.6kg, and further disease
progression was evident on a CT scan. The oncologist advised the
woman to stop etoposide and try single agent carboplatin
The oncologist calculated the woman's first dose of single agent
carboplatin. The Aesculapius prescription form shows that the
calculation of the dose of 600mg was based on her levels from 2012,
which were prepopulated into the Aesculapius programme (weight of
84kg and creatinine of 90mmol/L). The woman received this treatment
and at the woman's next consultation, the oncologist recorded that
the effect of the carboplatin seemed to be favourable. Further
doses of 600mg carboplatin were administered.
The woman was due for her next cycle of carboplatin, but her
blood counts were too low, so she did not receive it. She was
experiencing pain and fatigue. The oncologist recommended a change
to gemcitabine, and calculated a dose of 1950mg of gemcitabine
based on a weight of 84kg. The prescription noted that the woman's
creatinine was then 66mmol/L.
A chemotherapy nurse noticed that the woman had been receiving
chemotherapy based on a weight of 84kg, some 20kg more than her
then actual weight of 65kg. The oncologist directed that the
woman's dose of gemcitabine be reduced to 75% of the dose she had
been receiving because of the difficulty she was having with
cytopenia. The oncologist planned to send a new order sheet for
chemotherapy with the updated weight. There are no clinical notes
from the oncologist about the change in dosage. Over the next
months the woman's condition deteriorated, and she died.
The following factors contributed to the woman receiving a dose
of carboplatin calculated on the basis of her original measurements
than her current measurements, owing to systemic issues at
- Changes in patient information, on which prescriptions for
chemotherapy treatment were based (such as weight and creatinine
levels), could be recorded only in the chemotherapy treatment
computer system at DHB1, where it was based, and not by oncologists
working at off-site clinics.
- There were insufficient safeguards to identify the use of
historic data, and whether the weight and creatinine levels on the
day of delivery differed from that data. The oncologists were
unable to update patient details remotely, and the patient's weight
was not displayed prominently (or consistently) in the clinical
file, which meant that it was not necessarily brought to the
clinician's attention at clinic appointments.
Accordingly, DHB1 did not provide services to the woman with
reasonable care and skill and breached Right 4(1). Adverse comment
is made about the frequency with which the woman was reviewed by a
specialist while receiving chemotherapy.
Adverse comment is made about the oncologist not ensuring that
the calculations for treatment, which he signed off, were correct.
The oncologist was aware that the woman's weight was decreasing;
however, he failed to ensure that the Aesculapius programme was
updated when further doses of carboplatin were calculated.
Adverse comment is made about the lack of systems in place at
DHB2 to check that the data relied on was correct, prior to
administering chemotherapy treatment.
The Commissioner recommended that DHB1:
- provide a written apology to the woman's husband for its breach
of the Code.
- report to HDC with a detailed update on the effectiveness of
the changes made as a result of this case, including how
clinicians' ability to access the Aesculapius programme remotely is
affecting their service delivery; the results of the review of both
DHBs' models of service, and an assessment of the effectiveness of
the changes made to its service delivery following the review.
The Commissioner recommended that the oncologist report to HDC
on how the ability to access the prescribing software remotely has
affected his practice.
The Commissioner recommended that DHB2 report to HDC on the
effectiveness of the changes it has made, including the new
practice by DHB2 chemotherapy staff of weighing patients prior to
treatment, and notifying a clinician at DHB1 if a discrepancy is
detected against the script. The update should also provide details
on the changes made to Aesculapius, whether an onsite physician has
been appointed for the outreach clinics, and whether clinicians at
those clinics have adequate access to electronic databases,
including the Aesculapius programme.