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Patients Being Informed of Chemotherapy Drug Underdosing in Four Hospitals
Cyclophosphamide and gemcitabine purchased from drug manufacturer
Posted on 2013/04/02

Four Ontario hospitals are currently informing patients that they received lower than intended doses of cyclophosphamide and gemcitabine. The hospitals are London Health Sciences Centre, Windsor Regional Hospital, Lakeridge Health and Peterborough Regional Health Centre.

As each case is patient-specific, affected patients are being encouraged to discuss the possible effects of the under-dosing with their oncologists.

These two medications were purchased by the hospitals from a supplier who produces and labels these medications. Cancer Care Ontario and the affected hospitals are working closely with the supplier in order to find out the cause of the error.

This impacts 990 patients who received chemotherapy treatment with these two drugs since the following dates:

London Health Sciences Centre – since March 1, 2012.
  • 665 patients impacted
Windsor Regional Hospital – since February 24, 2012.
  • 290 patients impacted
Lakeridge Health – since March 12, 2013.  
  • 37 patients impacted
Peterborough Regional Health Centre – since March 20, 2013.
  • 1 patient impacted 

Upon discovery of the problem in late March 2013, all four hospitals immediately removed all cyclophosphamide and gemcitabine received from the drug manufacturer and informed the manufacturer of the error. Each hospital has secured appropriate supplies of the medications for all subsequent treatments. Patients’ treatment cycles will not be interrupted during this transition.

All four hospitals are working in partnership with Cancer Care Ontario to immediately notify all affected past and current patients or their families during the week of April 1.

“Cancer Care Ontario and its regional cancer programs are deeply committed to the safety of chemotherapy treatment for both patients and healthcare providers,” says Dr. Carol Sawka, Vice President of Clinical Programs and Quality Initiatives, Cancer Care Ontario. “It’s important to note that chemotherapy preparation and delivery is a complex process and as a result of this complexity, there are sources for potential error. In Ontario, we have put in many steps to minimize these potential sources of error and we will continue to ensure that patient safety and high quality care are the focus and the strength of the system.”

In addition to reaching out to affected patients or their families, each hospital has put in place measures to provide patients and family members with additional information and support, including a dedicated patient line, after-hours clinics staffed by healthcare providers and the opportunity to schedule an appointment with an oncologist to discuss any questions.

Hospitals have patient lines in place to support patients and their families, and to respond to questions they may have.

Patient Line Number
London Health Sciences Centre
or toll free 1- 855-464-3252
Windsor Regional Hospital
Lakeridge Health
905-576-8711, ext. 4655
Peterborough Regional Health Centre

Cancer Care Ontario – an Ontario government agency – drives quality and continuous improvement in disease prevention and screening, the delivery of care and the patient experience, for cancer, chronic kidney disease and access to care for key health services.


Cancer Care Ontario
Tori Gass
Phone: 1-855-460-2646

Lakeridge Health
Media line:
Phone: 905-576-8711 ext. 4317

Windsor Regional Hospital
Cathy Mombourquette
519.254.5577 ext. 58774
cell: 519-995-2533

London Health Sciences Centre
Media line:
Phone: 519-667-6760

Peterborough Regional Health Centre
Arnel Schiratti
Director, Strategic Communications and Engagement

Last modified: Thu, Apr 04, 2013
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