It is a “dramatic accident”. In May 2019, “a young patient died of an overdose of chemotherapy” at the Gustave Roussy cancer center in Villejuif (Val-de-Marne).
The tragedy, reported by doctors from the center this Thursday, July 24, 2019 on France 2, would have as origins in particular “recurring anomalies in the chain of control of the production of the delivery of chemotherapy” and “repeated errors leading to serious consequences”.
a Press release issued by the Gustave Roussy center affirms that “Gustave Roussy fully assumes the pharmaceutical error at the origin of the death and wishes to shed light on the causes of this tragedy and on the measures put in place so that no event of this nature can no longer reproduce (…) “.
A “human error in registering a product” in the pharmacy
In addition, “the precise analysis of the causes of death showed that it was a human error of recording a product in the stock of the pharmacy under a bad reference, which was not detected then during the preparation of chemotherapy, despite the four controls that exist during production “.
According to France 2, at the center (which receives 14,000 patients each year, treated by more than 250 researchers and 500 doctors) nearly 300 chemotherapy bags are prepared each day, manually or by two robots.
“But for two years, the service has been under tension because of personnel problems and more and more patients to be treated, according to the management and the unions” specifies France 2. However, the Gustave Roussy center wants to be reassuring: “the errors that may lead to clinical consequences are exceptional and dealt with immediately within the framework of a risk management system making it possible to adapt the security systems as quickly as possible and thus prevent their reproduction “.
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