Eastern Health may discipline lab staff

The head of a St. John's-based health authority plagued by a new set of laboratory mistakes says staff may be disciplined for failing to document problems and alert managers.

Eastern Health revealed Tuesday that almost a month passed before senior managers learned there had been problems with the immunosuppressive drug cyclosporine.

Chief executive officer Vickie Kaminski told reporters the authority may take action against staff for not following protocols that require occurrence reports when equipment is not working properly.

"It is a serious breach of hospital policy," Kaminski told reporters.

Kaminski herself did not learn of the problem until mid-February, when a 14-year-old boy who had received an excessive amount of cyclosporine was admitted to intensive care.

The importance of occurrence reports was highlighted in the Cameron inquiry report, which examined how hundreds of breast cancer patients in Newfoundland and Labrador had had inaccurate hormone receptor test results.

In a stinging report, Justice Margaret Cameron criticized the lack of record-keeping at Eastern Health, and recommended that the authority enact stronger rules for documenting errors, and then acting on them.

Kaminski, recruited to Eastern Health last year to help reorganize the troubled health authority, said she was disturbed to learn there had been no paper trail on the cyclosporine problems until she was briefed.

"Our policies were actually strengthened fairly significantly from the Cameron review, and so those policies were made widely available and certainly staff know about it, and that was not followed."

Focus on biochemistry lab

The Cameron inquiry focused largely on the authority's pathology lab.

The current problems with cyclosporine, which is administered for a variety of reasons, involve the biochemistry lab.

"[It's] frustrating, and certainly something that we're going to pay particular attention to," she told reporters.

Eastern Health's own review, which highlighted how managers had not been alerted to problems in a timely manner, found that no documentation had been generated when a mass spectrometer in the biochemistry lab began producing inaccurate readings involving cyclosporine.

No documents were filed in mid-January, when a nurse noticed a problem, or weeks later, when a doctor voiced concerns.

Kaminski said there was still nothing when she was finally brought into the loop last month.

"The occurrence report was asked for on [Feb. 19], and was completed over that weekend," she said.

"Remember, it was the first time I was hearing about it, and I said I'd like to see the occurrence report."

Eastern Health believes that 212 patients may have received too much cyclosporine. In excessive doses, it can cause kidney damage.

Staff with Toronto's University Health Network have agreed to conduct an external review of Eastern Health's biochemistry lab.