Changes made at Alberta Children's Hospital after report into series of errors

CALGARY - Alberta health officials say they've made changes after an independent review into a string of mistakes at a Calgary children's hospital last year, including two drug overdoses and a child given the wrong breast milk.

But the head of the group that did the review says more information should be available to the public about exactly what happened and what changes were recommended.

The Health Quality Council of Alberta was called in to investigate after four serious mistakes were made on the same unit of the hospital in February and March of 2009.

The council's executive summary was released Tuesday, along with a list of 18 recommendations being implemented, but the full report and all 85 recommendations made were withheld for privacy reasons.

An edited report is being put together, but health officials couldn't specify when it would be available.

"We're going to be working on those recommendations very ardently," said Margaret Fullerton, the hospital's interim vice-president.

"The people and the staff who work here care passionately for the patients in this hospital and we are committed to the care we provide every day."

According to the executive summary, the first error occurred Feb. 6, when a two-year-old child was given five medications into a vein instead of through a stomach tube. That child became sick enough to need treatment in intensive care.

The next day, a four-year-old child was given fifteen times the recommended dose of a medication. The mistake was noticed until the following day, but the child did not become ill or need treatment.

Later in the month, a six-year-old child was given five times the recommended amount of a drug that suppresses the immune system in three separate doses. Tests in that child revealed bone marrow suppression.

A month later, a nine-day-old infant was given the wrong breast milk, but did not suffer any immediate negative effects.

Dr. John Cowell, head of the Health Quality Council of Alberta, said there were no connections between the four cases.

"It was coincidental that they all happened within a couple of (months) of each other in a single area of the hospital," he said.

Several of the recommendations were very specific.

For example, one recommendation was to change the equipment used so that a pump meant to sent drugs into a stomach tube is not physically capable of attaching to a different type of line. Another recommendation was to make it easy to check by computer when a medication is prescribed to make sure the amount given corresponds with a patient's body weight.

Other recommendations are more general and involve doublechecks for procedures and making sure staff are fully trained when they switch to a new unit.

Hospital staff wouldn't say whether any of the children involved had any long-term negative effects, citing privacy concerns.

"In general, nobody died from this and when children are exposed to more than the usual dose of medications, the good thing is in the vast majority of circumstances there are no either immediate and certainly no lasting impact," said Dr. Jim Kellner, the hospital's head of pediatrics.

They also refused to say whether any disciplinary action was taken against any of the staff members involved or whether any lawsuits have been filed against the hospital.

Cowell said he considered the report safe to release in its entirety without any editing, something he has repeatedly advocated to build public confidence in his group's investigations.

"We have a report which we think would be capable of being released but they have ... a right to determine whether that report is released and in what form," he said.

He said he'll push for a full, public document to be released as soon as possible to show that the hospital is taking problems seriously. He also thinks that people have a right to know which recommendations the province decided to adopt and those they didn't.

In the meantime, Cowell said, there's no need to fear care at the hospital is suffering.

"I think it's to their credit that there was a revelation of these incidents and that we were brought in to investigate them," he said.

"I would bring my grandchildren here in a heartbeat."