Systemic Treatment Administration

Published On: August 13, 2018

St. Thomas – August 13th, 2018 – In June 2018, Cancer Care Ontario (CCO) became aware of an issue relating to the administration of three systemic treatment drugs (Pembrolizumab, Nivolumab and Panitumumab) used to treat locally and advanced and metastatic cancers, where amounts of the drug remained in the IV tubing resulting in a reduction in intended dose delivery to some patients.

On June 26th, CCO sent a Safety Bulletin to all 74 Ontario hospitals that deliver systemic treatment asking them to review hospital policies and procedures for all low volume, high concentration medications, to ensure that the intended dose is reaching the patient. In total, CCO learned that 35 out of 74 hospitals identified process issues relating to the administration of the three drugs.

In response, St. Thomas Elgin General Hospital (STEGH) conducted a full investigation into how this variation potentially affected our cancer patients. Our investigation, in partnership with the London Regional Cancer Program at London Health Sciences Centre, concluded that six patients at STEGH received the systemic therapy drugs in question.

The clinical team underwent a detailed review of these patients’ medical charts and treatment histories and as a result of that review STEGH confirmed that there was no negative impact on the outcomes for these patients.

STEGH took immediate steps to correct the issue through changing practices related to flushing of the IV lines used for systemic therapy delivery. The patients involved in our investigation have been notified.

For further details, please visit the Cancer Care Ontario website, here.


For more information: Fiona Hill-Hinrichs 519-631-2030 ext 2184 or