Family Members - February 17, 2017

Sharing Their Son’s Story to Prevent Future Fatal Medical Errors

By Jessica Miller
This Fatal Medical Error Leads to His Inevitable Death | CONQUER Magazine

A few weeks after beginning treatment for non-Hodgkin lymphoma in 2005, 21-year-old Christopher Robin Wibeto told his mother Debra that he wasn’t afraid to die. The conversation stuck with her, because “at the time, dying wasn’t even a thought,” Debra said at a recent press conference organized by the National Comprehensive Cancer Network (NCCN).

The doctors had told Chris and his family that the chemotherapy was working, and the cancer had been reduced by almost 50%. But then, during the last round of chemotherapy that Chris was scheduled to receive at the hospital, a serious error would cause his death within a few days.

A Fatal Mistake

Chris was mistakenly injected with the chemotherapy drug vincristine via a syringe into the fluid in his spine, which is a fatal error that leads to inevitable death.

“In one instance everything changed. In one instance any chance we had been dreaming and hoping for had been squashed by a seemingly careless and avoidable mistake,” Debra said. “Everything seemed to be moving at a rapid pace, and at the same time in slow motion. It was like a bad dream that you can’t wake up from.”

Chris was transferred to another hospital. His oncologist there, Robert W. Carlson, MD, was the one to tell Chris and his family that the situation was irreversible and would ultimately be fatal.

Debra remembers the graceful and delicate way in which the doctor broke the news, and the equally graceful way that her son received it.

“Chris, upon hearing that his life would almost certainly end, just took a deep breath and said he understood. He didn’t shed a tear, he didn’t complain. He just took in this terrible news and went on. He was a strong young man,” she said.

As most mothers would do, Debra said she wished she could take her son’s place. “No you don’t, Mom,” is all that Chris replied.

“I can’t imagine what Chris was thinking in that moment,” she said. Her son died within 4 days. “I will always have the memories of those days. Sometimes I cherish them, and sometimes the pain they cause me is unbearable,” Debra said.

She takes solace in the conversation she had with Chris in the weeks earlier, knowing he wasn’t afraid to die.

Chris’ Legacy: “Just Bag It” Campaign

Dr. Carlson was motivated by Chris’ death to prevent such errors in the future. After becoming CEO of NCCN in 2013, he worked closely with that national cancer organization to help prevent medical errors with vincristine. “It’s a mistake that does not happen too often, but if it does happen once, it is too many,” Dr. Carlson said.

Debra and her husband Robin joined Dr. Carlson and NCCN in late 2016 to announce the launch of “Just Bag It,” a new program that provides guidelines to instruct healthcare providers to administer the chemotherapy drug vincristine through a mini IV-drip bag and never use a syringe to administer this drug.

At a press conference in 2016 announcing the launch of the program, Debra and Robin remembered their son, and explained what they hoped to achieve by sharing his story.

“To be honest, I wasn’t sure I’d be able to speak,” Debra said from the podium. “Obviously this brings up many memories, both positive and tragic. But when I thought about it, I realized if my speaking here today could save even just one life, it will be beyond worth it.”

Robin believes that if the guidelines for bagging vincristine had been in place when Chris was receiving the chemotherapy, the mistake would not have happened.

“Losing a loved one is terrible, but losing a child is the worst thing that can happen to a parent. It tore our hearts up,” Robin said. “We hope that this story will help in some ways to prevent another family from suffering this horrible loss.”

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