2 Kids With Cancer Get Accidental Overdoses

Two cancer-stricken children were mistakenly given chemotherapy overdoses by a doctor at Johns Hopkins Children’s Center, and one of them may have gone deaf as a result, health officials said Thursday.

The child who lost his hearing, a critically ill 2-year-old boy, received twice the correct dose of the cancer drug carboplatin on three successive days in late May, the state health department said.

A 3-year-old girl also was given an overdose around the same time, but the dose was corrected after one treatment and no harm was done, the agency said.

Carol Benner, director of the state Office of Health Care Quality, said Thursday the overdoses were the doctor’s error. She would not identify the doctor or the children.

“You would have hoped that a nurse would have picked it up or the pharmacy would have picked it up and it didn’t happen, so this is a clear example of a system’s breakdown,” Benner said.

Benner said hearing loss is a known risk of the medication, so it was not certain whether the boy’s deafness was a result of receiving too much. However, the overdose significantly increased the risk, she said.

Hospital spokesman Gary Stephenson issued a statement acknowledging the error.

“Hopkins deeply regrets the accidental dosing error with an anticancer drug being used to prepare a critically ill ... child for a bone marrow transplant,” the statement said.

He said the hospital had systems in place to make sure doses are correct. The hospital discovered the overdose during a routine check, he said.

The discovery of the boy’s overdose prompted hospital officials to review dosages for five other patients, and that turned up the second overdose.

The state agency could fine the hospital up to $10,000 and impose restrictions if Hopkins does not take steps to prevent another such accident.

Benner said the children’s facility has cooperated fully.

“This does not appear to be a pattern,” she said.

The boy who became deaf suffered from neuroblastoma, the third most common cancer in children and one that typically attacks the adrenal glands or nerves in the back of the abdomen. Benner said the child may be regaining some hearing, but it remains unclear how much.

She said the boy eventually did receive the bone marrow transplant and seems to be recovering.