Medication Safety Alert! March 14, 2019
In this week's issue:
- ISMP Calls on FDA – No More Syringes for Vinca Alkaloids!
- Don’t miss a persuasive article by David Marx – Reckless Homicide at Vanderbilt? A Just Culture Analysis
- Top 10 Tips for keeping pets safe around human medications
- Neuromuscular blocker storage
- Diluent given without vancomycin
- Package insert mistaken as label
Since January 2019, ISMP has learned about 4 children who received vinCRIStine erroneously by the intrathecal route of administration, each suffering a very painful death. Three of the children were from Guyana, and one was from Norway. The child from Norway had a brain tumor and was just 6 years old when vinCRIStine was injected into the spinal fluid via an intraventricular catheter instead of methotrexate. The three children from Guyana were just 3, 6, and 7 years old.
The most effective way to prevent patient harm is to supply all vinca alkaloids in minibags, thus avoiding the risk of...