Published November 20, 2013 (revised December 24, 2024)
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.
For example, an event 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 130 reported cases around the world of vincristine being mistakenly administered into the spinal canal. 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.
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.
Finally, in 2020 the US Food and Drug Administration (FDA) changed the labeling on vincritsine instructing healthcare practitioners to dilute the medicine in a minibag; instructions to prepare the medicine in a syringe have been removed.
We still want you to be aware of this issue so that no more fatal errors will occur.
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. If one of the medicines is vincristine, make sure that the medicine is diluted in a minibag, not a syringe, to reduce the risk of a fatal error.
