Help prevent fatal error during life-saving cancer treatment

 

A rare but fatal error can occur when the cancer medicine vincristine is given the wrong way. Vincristine is given intravenously (into the vein) to treat various types of cancer. It is often given in combination with another cancer medicine called methotrexate. Methotrexate can be given into the spinal canal (intrathecally). This helps prevent the cancer from spreading to the brain. If vincristine is mistakenly given into the spinal canal instead of the methotrexate, death is almost certain.

We recently learned about such an event that happened in 2010 involving an adult woman being treated for lymphoma (a type of cancer). She was to get intravenous vincristine as well as methotrexate into her spinal canal. The vincristine was accidentally given into her spinal canal. The error was noticed right away. The woman was admitted to the hospital and a procedure was done to try to remove the medicine form her spinal fluid. The woman had no complaints until 3 days later. Then, she complained of a headache, weakness in her legs, and hearing loss. She continued to get worse. Over the next two weeks she became unable to move her arms or legs, had trouble breathing, went into a coma, and died.

Since 1968 there have been 120 reported cases around the world of vincristine being mistakenly administered into the spinal canal.1 Most cases have resulted in death. In all of these cases, both medicines were put into syringes that looked alike. Most often, the syringes of medicine were prepared in the pharmacy and sent together to the unit where the drugs were to be given. The syringes of medicine were mixed up, and the vincristine was accidentally given into the spinal canal instead of the methotrexate. not in a syringe1

Although this type of error is rare, it can be easily prevented. For years, the World Health Organization (WHO) and ISMP have promoted using a minibag to administer vincristine instead of putting it in a syringe. A minibag is a small bag of fluid that medicines can be added to so they can be given intravenously. When a nurse, doctor, or other healthcare professional sees the vincristine in a minibag, it is clear that the medicine should be given intravenously. The amount of fluid in the bag makes it nearly impossible to give the medicine into the spinal canal. in a minibag1

We have written about this error and how to prevent it many times in our other newsletters for healthcare professionals. Recently, we received a suggestion from one of our readers to inform consumers about this issue. The reader suggested soliciting your help in preventing this fatal error from occurring. Our recommendations follow.

Here’s what you can do: If you or a family member is receiving treatment for cancer, learn about all the medicines that will be given. Ask for written information about each medicine. Ask for the dose of the medicine and how it will be given. Keep a log of all the medicines that were taken. If one of the medicines is vincristine, we encourage you to request that the medicine be provided in a minibag, not a syringe, to reduce the risk of a fatal error.

Reference

1) Seger AC. Personal communication from Andrew C. Seger, PharmD. Division of General Medicine and Primary Care. Brigham and Women’s Hospital, Boston, MA. September 3, 2013.

 

Created on November 4, 2013

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