JCAHO issues alert on fatal misuse of a powerful drug

Patients undergoing chemotherapy to fight leukemia and lymphoma are sometimes being accidentally injected with a powerful cancer-fighting drug in an incorrect way that results in death or permanent paralysis, according to an alert issued by JCAHO.

The drug vincristine has been widely and successfully used to treat cancer for many years, but the Joint Commission reports that the drug is sometimes mistakenly administered in the sac around the spinal cord ("intrathecal") instead of intravenously. The Joint Commission reports that the intrathecal injection of vincristine can be the result of a single error or a series of mistakes in a medication system.

These errors have continued to occur despite repeated warnings and extensive labeling requirements and standards. The Joint Commission issued the alert recently to more than 4,500 accredited hospitals nationwide to create new awareness of the problem and offer practical solutions to protect cancer patients from this type of medication error.

Michael R. Cohen, RPh, MS, ScD, president of the Institute for Safe Medication Practices in Huntingdon Valley, PA, says risk managers must act.

"This tragedy is so preventable, yet there have been many cases reported in the media of patients being injected with vincristine intrathecally," Cohen says. "These cases are especially tragic because the patients experience paralysis and a slow and extremely painful deterioration, which in nearly all cases results in death."

To reduce the risk of wrong-route errors involving vincristine, the Joint Commission recommends that health care organizations take these steps:

  • Dilute the drug in such volume that it prevents intrathecal administration.
  • Clearly label all vincristine syringes with this warning: "FATAL IF GIVEN INTRATHECALLY. FOR IV USE ONLY. DO NOT REMOVE COVERING UNTIL MOMENT OF INJECTION."
  • Prevent IV and intrathecal medications from being dispensed or administered at the same time, in the same place, ensuring rather that these two distinct procedures are carried out at different times and locations.
  • Have at least two caregivers conduct a "time out" before the patient receives vincristine to independently confirm the correct patient, the correct drug, the correct dose, and the correct route for administering the drug.