WHO: Dilute vincristine in a minibag
From the July 26, 2007 issue
Last week the World Health Organization (WHO) published a drug alert about vincristine following the death of a 21-year-old woman in Hong Kong who received vincristine via the spinal route. WHO noted that there are at least 55 other cases reported worldwide, all of which were preventable. The Organization suggested that administering vincristine in a diluted volume (e.g., 50 mL normal saline) via a minibag would help deter practitioners from administering the drug via a spinal route, which is almost always fatal. The alert also noted that ISMP supports the use of a minibag to deliver vincristine, as does the Safety and Quality Council in Australia. Based on input gathered from international experts and patient safety organizations, WHO concluded that vincristine (and other vinca alkaloids) should only be given IV via a minibag, not a syringe. The alert called upon individual institutions, professional bodies, and policy makers to research, develop, and promote the separation of IV 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 IV administration cannot be administered inadvertently via the spinal route and vice versa. You can view the complete alert if you visit: www.who.int/medicines/publications/drugalerts/Alert_115_vincristine.pdf.