Chemo scandal: Pharmacists’ regulator refuses to disclose inspection reports for implicated drug supplier Despite more nearly 1,200 Canadians receiving diluted chemotherapy medication, the public has received little information about what transpired.

By: Diana Zlomislic Tim Alamenciak and Wendy Gillis, Published on Fri Apr 05 2013

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The public agency responsible for licensing pharmacies in Ontario refuses to provide inspection reports for Marchese Hospital Solutions, the company that hospitals say supplied weaker-than-prescribed chemotherapy drugs for nearly 1,200 Canadian patients.

There is almost no information about what Marchese and companies like it do to keep patients safe. One researcher who investigates mistakes in health care has just launched a review of the issue.

“The study we’re doing addresses the question of how much error is occurring in the mixing process because we don’t know that with any degree of reliability,” said Tony Easty, a researcher with Toronto’s University Health Network whose review was prompted by his investigation of a fatal chemotherapy overdose in an Edmonton patient in 2006.

“We don’t know which processes are truly the optimal processes to follow,” said Easty. “We’re trying to bring evidence to that so you’re not just hoping double-checking is effective.”

His study, which focuses on hospitals that perform in-house mixing, could affect quality control in all facilities that compound chemotherapy drugs.

Ontario’s cancer care system was thrust into the spotlight this week when revelations of weakened chemotherapy doses surfaced. Outside of the fact that almost 1,000 patients in Ontario and 186 in New Brunswick were affected, the public has received very little information about what exactly happened.

Windsor Regional Hospital, where 290 people were affected, held its first town hall Friday for patients and their families. The sessions were described as emotional in a memo from hospital president David Musyj to its board of directors.

Three more patients who received the watered-down doses have since died, bringing the total to 20, according to the memo.

Investigations are underway by Cancer Care Ontario and the Ontario College of Pharmacists, in partnership with Health Canada. Premier Kathleen Wynne has also called for a yet-unnamed third-party to conduct a review.

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