Eight South Australian clinicians face the prospect of being deregistered after cancer patients at two Adelaide hospitals received incorrect chemotherapy treatment.
An inquiry found that five patients at the Royal Adelaide Hospital and a further five at Flinders Medical Centre were under-dosed between July 2014 and January last year because of a typographical error.
The inquiry also found staff at the hospitals failed to disclose the mistakes to patients or management.
Health Minister Jack Snelling told parliament on Tuesday that the clinicians responsible had been referred to the Australian Health Practitioner Regulation Agency (AHPRA).
AHPRA will report its findings to the Medical Board of Australia, which could take disciplinary action - including suspension or deregistration - if adverse conduct is discovered.
"This has been a serious failure in clinical governance," Mr Snelling said.
"Patients need to feel safe when they are being treated in our health system and I am angry and frustrated by the fact that systems put in place to protect patients have not been followed."
The Liberal opposition and independent MP John Darley have drafted terms for a parliamentary inquiry into the bungle.
Mr Snelling said he supported an inquiry in principle but asked that it be deferred until AHPRA had concluded its investigation.
The inquiry also found a similar typographical error involving the protocol for treating patients with aggressive lymphomas.
That error had potentially impacted on nine patients between 2005 and 2015 but only one person - who was now in remission - had received a lower-than-recommended dose of prednisolone.
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