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Single or Multiple Incident: Single
Date: 2/1/2019 12:00:00 AM
Country: Canada
Organization: Manitoba Health

This patient safety learning advisory describes a patient safety incident where a cancer patient was not considered for a stem cell transplant within the facility’s timelines due to miscommunication between departments and a missed physician’s order. A patient with lymphoma completed six cycles of r chemotherapy. A CT scan following this treatment showed the disease was still present. The hematologist ordered another chemotherapy regimen with a plan to follow with consideration for stem cell transplant. The patient received six cycles of the second chemotherapy regimen. The patient was then referred to Blood and Marrow Transplant (BMT) for consideration of stem cell transplant. The BMT service did not receive the referral. The patient was seen again a month later by the hematologist. At case conference it was decided that the patient would be referred for radiation therapy to treat the refractory disease, followed by a consideration for CAR-T Therapy. Standards of care for stem cell transplants indicate that patients with this disease should be seen by BMT prior to cycle four of chemotherapy. Due to the referral being delayed, BMT wasn’t able to assess the patient for stem cell transplant. Recommendations to prevent similar incidents are provided.



Communication between Departments