Accidental Intrathecal Administration of IV Vincristine

A recent Institute for Safe Medication Practices safety alert warns about the danger of accidentally administering IV vincristine by the intrathecal route. ISMP cites a recent case where a syringe containing vincristine was accidentally delivered to the wrong patient's bedside. A physician, believing it was a different medication intended for intrathecal use, delivered the vincristine intrathecally. The patient died three days later.

In the past, FDA and USP have urged that extemporaneously prepared IV syringes be labeled "Fatal if given intrathecally, for IV use only," and be over-wrapped with a similar warning label. The ISMP alert again stresses the importance of using this kind of labeling for intrathecal medications to prevent confusion with IV medications.

ISMP recently asked several hundred hospitals what they do to avoid accidental intrathecal administration of IV vincristine. In addition to the warning labels, here are some of the methods these institutions reported using:

• Some hospitals only deliver IV vincristine to areas where intrathecal drugs are prohibited.

• Others use distinctive packaging, such as unique overwraps, for intrathecal medications.

• Some dilute IV vincristine in a plastic minibag before use, which helps distinguish it from syringes of intrathecal medications.

• Some have two health professionals independently check IV vincristine doses before administration, and others continually monitor the patient at the bedside when delivering IV vincristine.

• For patients receiving medications by both routes, some hospitals verify that the IV medication has been administered before administering the intrathecal medication, and vice versa.

ISMP stresses that patients usually die slowly and painfully when IV vincristine is accidentally administered intrathecally, and that their deaths can be prevented with relatively simple precautions like these.

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• Accidental
• Intrathecal
• Administration
• of
• IV
• Vincristine
• Patient
• Death
• Drug
• Reaction
• Safety