Officials at Windsor Regional Hospital say they will take two weeks to review a report that examined the circumstances that led to 1,202 cancer patients receiving watered down chemotherapy drugs.
The report, commissioned by Ontario's Ministry of Health, makes 12 recommendations. Among them, Health Canada should regulate all entities that mix drugs outside a licensed pharmacy. It also urged Ontario to implement stronger rules for licensed pharmacies, by inspecting and licensing those in the province's clinics and hospitals as well as pharmacies that prepare large volumes of drug mixtures.
Windsor Regional Hospital's CEO, David Musyj, says all 12 recommendations are attainable.
"Everybody plays a part in fixing this. That includes Windsor Regional Hospital, hospitals across Ontario and Canada. Every entity plays a part," Musyj said. "That's the only way we're going to fix this."
The report does not single out any one person, hospital or healthcare company as being at fault. Instead, it looks at the process.
Extra saline in bags containing cyclophosphamide and gemcitabine effectively watered down the prescribed drug concentrations by up to 10 per cent, the report found.
Marchese Hospital Solutions, which provided the mixture to four hospitals in Ontario and one in New Brunswick, fell in a jurisdictional grey area, with the federal government and Ontario College of Pharmacists unable to agree on who was responsible for the facility.
Dr. Jake Thiessen, who investigated the mistake, said he found flaws throughout the cancer drug supply chain.
"All levels of the drug chain had shortcomings," he said after releasing his report.
Thiessen concluded that there was "no evidence of any malicious or deliberate drug-sparing dilution" by Marchese.
The hospitals weren't aware that the bags contained extra saline and didn't adjust the doses accordingly.
"We need to know, step by step by step during the procurement process, who is responsible for what," Musyj said.
The report does not recommend hospitals stop outsourcing the mixing of drugs.
Marchese told CBC News in a statement it's pleased the report did not tell hospitals to stop outsourcing the mixing of drugs.
However, Musyj said Windsor Regional Hospital will no longer be collaborating again with Marchese.
Until the province or Health Canada implement new policies governing the mixing of drugs, Windsor Regional Hospital will be mixing the treatments in house.
Cancer patient Kate Warner of Windsor was one of those who was not receiving the right dose of medication to treat her breast cancer.
She's not pleased with the report.
"Somebody's got to step up and say, 'yes, we're responsible for this and it won't happen again,'" she said. "It sounds to me like [no one is] really accepting the blame but they're still apologising for it. I don't see that it's going to do us any good at all."