South Australia's chemotherapy dosing bungle involved a "disturbing and indefensible" failure in clinical governance, a damning new report has found.
SA Health has released a review from the Australian Safety and Quality Commission into the bungle, which involved 10 leukaemia patients being underdosed at two Adelaide hospitals between June 2014 and January 2015.
The report says staff involved had little or no knowledge of SA Health's incident management guidelines and failed to make an incident report soon enough.
An incident report was not lodged until nearly a month after a senior doctor at the Royal Adelaide Hospital realised patients were receiving the wrong dose, because of a typographical error in a new hospital treatment protocol.
The investigation says the hospitals also poorly handled informing those affected, and some patients were told alone, without notice, when they came in for treatment.
"The management of this incident demonstrated a disturbing and indefensible failure in clinical governance," the report said.
"CALHN (Central Adelaide Local Health Network) should review its clinical governance framework, structures and procedures to ensure that they provide robust clinical governance."
The report makes six recommendations to SA Health including better training for staff in incident management and handling informing and compensating patients more sensitively.
"We accept all of the report's recommendations and are committed to implementing the changes needed to ensure these mistakes are never repeated," SA Health interim chief executive Vickie Kaminski said.
Opposition health spokesman Stephen Wade said the report showed the government had been downplaying the depth of issues behind the bungle.
"We've been told for months now that this was an isolated incident and it's been dealt with, nothing to see here. What this report shows is this is a department-wide problem," he told ABC radio on Friday.
