Has anyone been given the wrong drug at chemo? (Beva when not supposed to)

[Itsholly]

Hi

i wasn’t sure how to word this but I am trying to gauge if this is common.

a relative is having three weekly cycles of chemo with carbo / plato / beva - sorry for the wrong terms but you may know what I mean.

the third cycle is the one before surgery so they said that they would not give the beva as you cannot have this close to surgery.

there was a mix up on the prescription and they administered the beva. There was no prior check of what they were giving. Just went ahead and did it.

Has anyone come across this before?

This mistake is going to mess up the planned surgery dates now and we do not know whether they will delay surgery, give another round of chemo or what and whether this could have an adverse impact on figuring the cancer.

Have they been in contact with consultant or nurse specialist yet to ask?
Did they not say when they were told it had happened? Stressful time for them!

It hasn’t happened to me but it will be registered via the hospitals own reporting system and investigated. Then people will either get into trouble (likely to be the nurse as it’s always their fault!) or processes will get assessed and changed as several checks should have been in place but clearly weren’t.
In regards to your relative they should have a new treatment plan discussed with their consultant who will decide the risks of leaving surgery versus the risk of carrying out surgery after the drug has been given and make a decision based on the evidence and clinical data.
Your relative should also be given an apology and reassurance this is being investigated.

It happened yesterday and the chemo nurses said that it matched the prescription they had so that in what they went by. But my relative had a letter that just had the carbo : plato on it and we knew that was going to be the case anyway due to forthcoming surgery. I think the issue may rest with the oncologist that issued the prescription

We called the number and left a voicemail when relative returned from treatment but it was out of hours so hoping they will call back first thing with a proactive investigation and reassurance regarding plan from here - without much waiting as that’s the worst bit!

We called the number and left a voicemail when relative returned from treatment but it was out of hours so hoping they will call back first thing with a proactive investigation and reassurance regarding plan from here - without much waiting as that’s the worst bit!

This should be recorded as a never event. Did they tell you or did you find out? They have a duty of candour to tell you when they realise a mistake has been made.

You are entitled to make a complaint.

I suspect the surgery will get pushed back a couple of weeks. I can imagine how it happened but so sorry extra stress at this time x

It’s not a never event, but this is either a significant error by the prescriber, or a massive communication cock up between the surgery team and the oncology team.

If the nurses are aware the issue may already have been escalated but if you don’t get contacted today go via PALS.

Yes of course make a complaint but what you really need is a clinical decision to be made about what happens now

Oh, and it doesn’t matter whether it’s common - it should not have happened. Unless the surgery date had already been rescheduled and you had not been told - which would still be unacceptably poor communication.

Also this!

A Patient Safety Incident Investigation is needed to confirm. If the chemo was prescribed and the nurses administered against prescription then the error is with the prescriber and not the nurses. As @SnakesAndArrows said a cock up between the teams

It was prescribed. But is shouldn’t have been. There have been three different oncologists as the first one went on holiday, the second one was a stand in and seemed quite flippant and the third one was a telephone call from over 100 miles away. None of them clarified (except the first one that said about it not being needed on the third round) what the next treatment would involve during the consultations. Everyone has been fantastic except from the flip flopping with oncologists that on occasion do not appear to have read the records prior to discussion.

I completely agree with you. I think I asked if it was common as my instinct is that this is really bad to have happened but I wasn’t sure if I was blowing it out of proportion.

Relative discovered the mistake as they saw hand written note that stated beva. Asked if it had been administered and it had. Wonder whether this would be identified otherwise with surgery going ahead if they hadn’t picked up on it themselves.

This must be very distressing. Do engage with PALS to ensure you relative's distress is acknowledged and responded to appropriately.

A side effect of Beva is impaired wound healing so surgery when Beva has been given recently could mean that the incision site doesn't heal properly and would be a higher risk of infection. They would consider going ahead with surgery anyway if a delay might be detrimental for other equally serious reasons, but it is more likely they would postpone. They will bring forward other planned surgeries that were scheduled over the next few weeks and give your relative a slot 2-3 weeks later than it might have been to give the body time to process and eliminate the Beva. They probably won't prescribe an additional round of chemo - they certainly won't if they know it's a relatively slow-growing type, but would consider it if there is evidence that with this particular type it is beneficial to keep the chemo going until close to the surgery date. The oncologist will make the call on that.

That’s exactly why they said no beva before surgery due to the wound healing issue. Very distressing especially if they do still want to go ahead with surgery despite beva risks as it is already a very complex surgery.

it’s the distress side of it I wish I could take away.

not had any involvement with pals not sure whether to see if our call back is returned this morning and give them a chance or go straight to pals. There is a part of me that doesn’t want to cause a fuss and deal with it in a reasonable way whilst also advocating appropriately for relative.

You are not overreacting. The key is to remain calm, firm, and be clear what you want to know, and what you want to happen.

This is not “making a fuss” - it is advocating for your relative to ensure the effects of this error on his/her treatment and prognosis are mitigated as far as possible. An apology and reassurance that lessons will be learned are secondary concerns.

Good luck.

On one occasion I was told I was down for the chemo drug when I was expecting a monoclonal antibody. I raised it with the nurse and they checked and changed it. I think my consultant had made an error or perhaps changed his mind. The nurses are supposed to say clearly what you are being given (or so I believe!).

Of course for a vulnerable patient the nurse might say it correctly and still go ahead.

Ideally we could all be confident of being given the right drugs!