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NCCN Campaign May Prevent Fatal Medication Errors by Targeting Vincristine Preparation

TOP - February 2017, Vol 10, No 1 - Best Practices
Caroline Helwick

Philadelphia, PA—A persistent medi­­cation safety issue is getting the attention it has long deserved. In an effort to save lives related to the accidental intrathecal dosing of vincristine, the National Comprehensive Cancer Network (NCCN) has launched a program called “Just Bag It: The NCCN Campaign for Safe Handling of Vincristine.”

Many agents used in combination with vincristine are delivered intrathe­cally. If vincristine is mistakenly in­­jected into the spine, it is uniformly fatal, as described by speakers at an NCCN press briefing that was intended to increase awareness about this rare but serious and preventable drug safety issue.

According to Michael Cohen, RPh, MS, President of the Institute for Safe Medication Practices, patients experience paralysis and neurologic defects “leading to a very painful and agonizing death.” Accidental injection and resulting death are prevented when vincristine is diluted within an intravenous drip bag and not put into a syringe.

Robert W. Carlson, MD, Chief Executive Officer, NCCN, introduced the campaign by describing his own heartrending experience in caring for a 21-year-old patient with Hodgkin lymphoma. While Dr Carlson was an oncologist at Stanford University, Christopher Wibeto was transferred to his care after having vincristine incorrectly administered at another institution.

“These medical errors are not just statistics. They impact people in a very negative way. It was devastating to know this was happening to Chris because of an error that could have been prevented,” Dr Carlson said.

Christopher’s parents also addressed the media. “When we were told about this campaign, we wanted to do what­­ever we could do to raise awareness about this error so no other family will lose a loved one like we did. Had a procedure for bagging been in place at that time, the error that took Chris would not have happened. We urge all medical facilities to ‘Just Bag It,’” Robin Wibeto commented.

An increasing number of hospitals have adopted a policy to always bag vincristine; however, only 50% of hospitals indicate that the policy is implemented throughout their institutions, an Institute for Safe Medication Practices survey showed.

Dr Carlson said there have been approximately 125 documented cases of accidental death related to incorrect administration of vincristine since the 1960s, but he believes many more go unreported.

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Last modified: September 9, 2019