The Alberta Children's Hospital outlined steps it took for patient safety after four medication errors in 2009. (D'Arcy Norman)

Failures to implement recommendations from previous incidents and poor communication led to unrelated errors — including two non-fatal drug overdoses — at the Alberta Children's Hospital, a review has concluded.

Four serious patient care incidents happened in the same nursing unit at the Calgary hospital in February and March 2009, leading to the investigation by the Health Quality Council of Alberta.

Alberta Health released a summary of the independent body's findings on Tuesday, withholding the full 58-page report citing confidentiality concerns.

On Feb. 6, 2009, a two-year-old child received intravenously five oral medications that should have been administered through a gastronomy tube for an enteral, or digestive tract, feed.

The review found the error occurred because a pump, tube and syringe system that works for both intravenous and enteral methods was used. That error was compounded by a failure to trace the lines, which were also unlabelled.

"A similar incident occurred about three years prior and recommendations to mitigate the recurrence of such an event were not fully implemented," according to the council.

The toddler required treatment in the pediatric intensive care unit.

Tot got narcotic overdose

On Feb. 7, 2009, a four-year-old patient received a 15-fold overdose of a narcotic called fentanyl through an IV.

"Ineffective communication" between a doctor and nurse about the verbal order for a painkiller, using the wrong reference chart and failure to double-check the dosage led to the mistake, the review said.

'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.'— Margaret Fullerton, Alberta Children's Hospital

On Feb. 24, 2009, a six-year-old child received a five-fold overdose of azathioprine, an immunosuppressive drug.

That error came about from the "absence of a medication reconciliation process," said the council, adding that doctors, nurses and pharmacists failed to perform a check on what the safe dosage would be for that child's weight.

Lab results showed evidence of bone marrow suppression in the child.

On March 31, 2009, a nine-day-old infant received breast milk that did not come from the mother.

The review noted that a failure to implement almost a dozen recommendations from a 2006 review into similar breast-milk errors led to the March mistake.

Mum on any disciplinary action

Hospital officials refused on Tuesday to comment on the children's current condition, or whether staff faced any disciplinary action, citing confidentiality reasons. They said they met with and apologized to all the parents involved and asked them for input.

"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.

Some of the review's 84 recommendations are already being implemented at the hospital and across Alberta Health Services facilities including:

• Developing standardized procedures for tracing and labelling all infusion lines.
• Making equipment adjustments to eliminate the ability to connect gastronomy tube products to intravenous lines.
• Ensuring the computer system allows clinicians to cross-check medication dosage against patient weight or body surface area.

Actions taken by the hospital include:

• Reinforcing existing processes for storing, requesting and feeding breast milk, including requiring the signatures of both clinician and parent.
• Ensuring refrigerators for storing breast milk are secure and not widely accessible.

"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."

A second investigation by Alberta Health Services into the human factors involved continues, but will remain confidential because of personnel matters, officials said.

With files from The Canadian Press