Chemotherapy medication mixup may be fatal

AORN Journal, Nov, 2005

An alert issued by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) reports that patients undergoing chemotherapy to fight leukemia and lymphoma are sometimes accidentally being injected with a powerful anti-cancer medication in an incorrect way that results in death or permanent paralysis, according to a July 14, 2005, news release from JCAHO. The medication vincristine has been used widely and successfully to treat cancer for many years, but sometimes the medication is mistakenly administered in the sac around the spinal cord (ie, intrathecal) instead of intravenously.

Intrathecal administration of vincristine can be the result of a single error or a series of mistakes in a medication system, and these errors have continued to occur despite repeated warnings and extensive labeling requirements and standards. The Joint Commission alert recommends that hearth care organizations

* dilute the medication in such volume that it prevents intrathecal administration;

* clearly label all vincristine syringes with the warning that vincristine is fatal if given intrathecally and is for IV use only;

* ensure that IV and intrathecal medications are dispensed or administered at different times and in different locations; and

* have at feast two caregivers conduct a time out before the patient receives vincristine to independently confirm the correct patient, medication, dose, and route for administering the medication.

Joint Commission Issues Alert: Mixups in Administering Chemotherapy Drug Lead to Deaths (news release, Oakbrook Terrace, III: Joint Commission on Accreditation of Healthcare Organizations, July 14, 2005).