April 8, 2008: World Health Organization Recommendations for Vincristine
Vincristine, a chemotherapy agent, should always be administered intravenously, never by any other route. On July 7, 2007, a 21-year-old woman died in Hong Kong after this drug was inadvertently administered by the spinal route. According to the World Health Organization (WHO), since 1968 this error has been reported a total of 55 times from a variety of settings around the world. In response to the Hong Kong incident, the WHO issued an international alert (see http://www.who.int/patientsafety/highlights/PS_alert_115_vincristine.pdf) which includes recommendations that are in line with information published in 2001 by ISMP Canada ( http://www.ismp-canada.org/download/ISMPCSB2001-10Vincristine.pdf ).As stated in the alert, the WHO World Alliance for Patient Safety recommends:
“1) The labelling of vincristine should include a clear warning label that reads: ‘FOR INTRAVENOUS USE ONLY - FATAL IF GIVEN BY OTHER ROUTES’.
2) Syringes should not be used for vincristine administration.
3) Vincristine should where possible be prepared by dilution in small volume intravenous bags (the ‘minibag’ technique), rather than in a syringe, to protect against accidental administration via a spinal route.”
The WHO further commented that research is needed to develop and promote a long-term solution that will separate intravenous and spinal delivery systems. “The gold standard is to create a unique ‘lock and key’ design of needles, syringes, catheters, tubing and bags so that medications intended for intravenous administration cannot be administered via the spinal route and vice versa.”
