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IV vincristine survey shows safety improvements needed

From the February 23, 2006 issue

We received more than 400 responses to a survey on IV vincristine safety practices published in our December 4, 2005, newsletter, which was prompted by yet another death from intrathecal administration of IV vincristine. Overall, results showed that pediatric, outpatient, and specialized oncology facilities had employed many of the specified error-reduction strategies more frequently than adult, inpatient, and general acute care facilities. Nevertheless, widespread application of these relatively simple error-reduction strategies is still needed in all settings to avoid further tragedies, as the survey findings suggest (see Table below).

Diluting the drug. About a quarter (23%) of all respondents dilute IV vincristine in minibags, and half (53%) dilute the drug in syringes, before dispensing and administering it. So together, three-quarters of respondents dilute IV vincristine before use, most often in 50 mL (44%) or 25 mL (18%).

Of course, these findings suggest that a quarter of respondents do not dilute IV vincristine before use, thus missing a crucial error-reduction strategy. Diluted IV vincristine is less likely to be administered intrathecally due to the volume of solution. Use of a minibag offers further differentiation since intrathecal medications are often dispensed in a syringe.

Some opponents of dilution cite the risk of extravasation as a significant deterrent, especially if the patient’s access line is not continually assessed for patency. However, in general, survey respondents from all types of facilities reported similar frequencies of extravasations when administering diluted or undiluted IV vincristine. Furthermore, respondents reported that all extravasations with diluted drug during the past 2 years (n=15) were mild in severity, whereas mild (n=11), moderate (n=7), and severe (n=2) extravasations were reported during the same period when administering undiluted IV vincristine.

Distinctive packaging. More than half of all respondents reported that intrathecal medications are packaged in a distinctive manner (e.g., use of unique overwraps) to prevent confusion with IV medications, particularly IV vincristine. Pediatric facilities reported using this error-reduction strategy more frequently than adult facilities, as did outpatient facilities when compared to inpatient facilities, and specialized oncology facilities when compared to acute care facilities.

Reminders. Despite a 1991 FDA and USP requirement, 7% of all respondents did not comply by affixing special warning labels (FATAL if given intrathecally, FOR IV USE ONLY) on extemporaneously prepared doses of IV vincristine, and 24% did not place the doses in manufacturer-supplied overwraps with a similar warning. Better compliance was reported in pediatric facilities. In this case, inpatient facilities fared better with applying warning labels on each dose than outpatient facilities, but neither fared well with placing the dose in an overwrap with warning labels.

Redundancies. Most respondents (94%) reported that two health professionals independently check IV vincristine doses before administration, with little differences between respondent groups with one exception; pediatric facilities reported that these checks always occur. On the other hand, just three-quarters of all respondents required an independent check of IV vincristine doses before dispensing the drug. Inpatient facilities faired a little better with independent double checks in the pharmacy before dispensing IV vincristine doses.

Limit access. About a quarter of all respondents only deliver IV vincristine to a location where intrathecal drugs are prohibited, more so in outpatient facilities. Only a third of all respondents prohibit IV vincristine administration in the same location where intrathecal medications are given. This error-reduction strategy was more prevalent in outpatient, pediatric, and specialized oncology facilities. Similar results were reported with banning IV vincristine from rooms where lumbar punctures are performed.

Verification. Less than half of all respondents verify that an intrathecal medication has been administered before dispensing IV vincristine (or vice versa) for patients who are receiving medications by both routes. Again, pediatric, outpatient, and specialized oncology facilities had implemented this process more often than adult, inpatient, and acute care facilities.

Patient monitoring. Practically all respondents reported that a trained licensed practitioner remains at the bedside to continually monitor the patient and assess IV patency and signs of extravasation when administering undiluted IV vincristine. Fewer follow this practice when administering the diluted drug. (Although extravasations are reportedly less severe with diluted IV vincristine, bedside monitoring of patients during administration is still crucial given the risk of harm from extravasations.)

Conclusions. Since 1989, ISMP has repeatedly published reports of fatal errors caused by inadvertent administration of IV vincristine by the intrathecal route. Most survey respondents (90%) reported that they have alerted staff to these and other published errors. Awareness of the risk for such tragedies is certainly needed and should reach all who dispense or administer chemotherapy or intrathecal medications. However, awareness alone is not enough. Regardless of the setting in which IV vincristine is dispensed and administered, the relatively easy safety measures mentioned above must be given the highest priority for full implementation. After all, patients rarely survive after IV vincristine has been administered intrathecally, and the subsequent decline until death is slow and excruciatingly painful, both emotionally and physically. No more evidence than this should be needed to raise the urgency with which organizations pursue eradication of this rare but fatal and preventable error.

Selected results from 2005 ISMP Vincristine Survey* Patient Population Setting Type of Facility
Error Reduction Strategy Implemented All Respondents (n=409) Pediatrics Only (n=48) Adults Only (n=258) Outpatient (n=68) Inpatient (n=65) Specialized Oncology (n=127) Acute Care (n=269)
Intrathecal medications packaged distinctively different than IV vincristine 55% 63% 52% 59% 48% 63% 52%
Special warning to extemporaneously prepared doses of IV vincristine 93% 98% 90% 85% 97% 90% 94%
IV vincristine placed in manufacturer’s overwrap with special warning 76% 91% 73% 66% 77% 77% 75%
Double check before administration 94% 100% 93% 93% 95% 94% 94%
Double check before dispensing 76% 76% 76% 77% 86% 72% 77%
Delivery to area where intrathecal medications prohibited 23% 19% 23% 30% 14% 26% 22%
Prohibited where intrathecal medications are administered 38% 69% 34% 42% 30% 46% 34%
Banned from lumbar puncture rooms 40% 77% 35% 53% 21% 51% 35%
Verification of completed intrathecal administration prior to dispensing 42% 51% 40% 47% 34% 55% 36%
Doses diluted and dispensed/administered in a minibag 23% 8% 25% 10% 35% 16% 27%
Doses diluted and dispensed/administered in a syringe 53% 58% 53% 54% 54% 56% 51%


*Full survey results can be found here


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