BOSTON—In July 2005, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) issued a sentinel event alert on the prevention of inadvertent intrathecal (IT) administration of vincristine. At the 31st Annual Congress of the Oncology Nursing Society (abstract 22), Maria (Monny) Slezak, RN, BSN, OSN, discussed how her institution responded to the alert to help "preserve the center's zero-error rate." Ms. Slezak is clinical director of oncology services at the University of California, San Diego (UCSD) Medical Center-Moores UCSD Cancer Center.

Ms. Slezak called IT administration of vincristine, "a potentially fatal yet very preventable error." Cases are rare but usually have tragic results. In the United States, she said, three databases have reported 12 cases: Three of these errors were caught before reaching the patient, two patients had permanent paralysis as a result of IT vincristine administration, and there were five deaths, one unspecified injury, and one unknown result.

Authorities in the United Kingdom have reported 14 cases of IT vincristine administration since 1975.

"Despite specific requirements for labeling and a rigid dispensing standard imposed by the United States Pharmacopeia (USP), these errors continue to occur," Ms. Slezak said.

Recommendations

In response to the JCAHO alert, UCSD added the JCAHO recommendations for preventing vincristine administration errors (see Table) to the center's own policy on handling and administering antineoplastic drugs, and also implemented other safeguards.

At UCSD, Ms. Slezak said, "vincristine will always be dispensed by pharmacy diluted in a minibag; it will no longer be dispensed in 3 mL syringes. Vincristine should be administered over 5 to 10 minutes. If it is to be administered via peripheral access, the nurse should stay at the bedside to check blood return for potential extravasation during the 5- to 10-minute infusion period."