Inadvertent intrathecal administration of vincristine: Are we fulfilling our roles as oncology pharmacists?

Journal of Oncology Pharmacy Practice

Volumn 10, Issue 4, 2004, Pages 187-189

  Gilbar, Peter ^a   Dooley, Michael ^b   Brien, Jo Anne ^c  

^a Toowoomba Health Services   (Australia)

^b MONASH UNIVERSITY   (Australia)

^c UNIVERSITY OF SYDNEY   (Australia)

Author keywords

[No Author keywords available]

Indexed keywords

METHOTREXATE; VINCRISTINE;

BURKITT LYMPHOMA; CLINICAL PRACTICE; DRUG LABELING; DRUG PACKAGING; DRUG SAFETY; DRUG SURVEILLANCE PROGRAM; EDITORIAL; EXTRAVASATION; HEALTH CARE PERSONNEL; HUMAN; MEDICATION ERROR; NEUROTOXICITY; PARALYSIS; PRESCRIPTION; PRIORITY JOURNAL; RISK REDUCTION;

EID: 13444292470     PISSN: 10781552     EISSN: None     Source Type: Journal    
DOI: 10.1191/1078155204jp134ed     Document Type: Editorial

References (17)

1. Cohen MR, Anderson RW, Attililo RM, Green L, Muller RJ, Preumer JM. Preventing medication errors in cancer chemotherapy. Am J Health Syst Pharm 1996; 53: 737-46.
2. Fischer D, Alfano S, Knobf MT, Donovan C, Beaulieu N. Improving the cancer chemotherapy use process. J Clin Oncol 1996; 14: 3148-55.
3. Goldspiel BR, DeChristoforo R, Daniels CE. A continuous-improvement approach for reducing the number of chemotherapy related errors. Am J Health Syst Pharm 200; 57: S4-S9.
4. Womer RB, Tracy E, Soo-Hoo W, Bickert B, DiTaranto S, Barnsteiner JH. Multidisciplinary systems approach to chemotherapy safety: rebuilding processes and holding the gains. J Clin Oncol 2002; 20: 4705-12.
5. Schochet SS, Lampert PW, Earle KM. Neuronal changes by intrathecal vincristine sulfate. J Neuropathol Exp Neurol 1968; 27: 645-58.
6. Dyer C. Doctors suspended after injecting wrong drug into spine. BMJ 2001; 322: 257-58.
7. Woods K. The prevention of intrathecal medication errors. A report to the Chief Medical Officer. Department of Health, London; 2001. Available from www.doh.gov.uk/imeprevent/index.htm.
8. Dettmeyer R, Driever F, Becker A et al. Fatal myeloencephalopathy due to accidental intrathecal vincristine administration: a report of two cases. Foren Sci Int 2001; 122: 60-04.
9. Alcaraz A, Rey C, Concha A, Medina A. Intrathecal vincristine: fatal myeloencephalopathy despite cerebrospinal fluid perfusion. J Toxicol Clin Toxicol 2002; 40: 557-61.
10. Reason J. Human error: models and management. BMJ 2000; 320: 768-770.
11. Fernandez CV, Esau R, Hamilton D, Fitzsimmons B, Pritchard S. Intrathecal vincristine: an analysis of reasons for recurrent fatal chemotherapeutic error with recommendations for prevention. J Ped Hemat Oncol 1998; 20: 587-90.
12. Lanigan CJ. Safer epidural and spinal connectors. Anaesth 2002; 57: 567-71.
13. Palmieri C, Barron N, Vigushin DM. The Vincotube System: A design solution to prevent accidental administration of intrathecal vinca alkaloids. J Clin Oncol 2004; 22: 965.
14. Stefanou A, Dooley MJ. In reply. J Clin Oncol 2004; 22: 965-66
15. Stefanou A, Dooley M. Simple method to eliminate the risk of inadvertent intrathecal vincristine administration (letter). J Clin Oncol 2003; 21: 2044-47.
16. Mullin S, Beckwith MC, Tyler LS. Prevention and management of antineoplasic extravasation injury. Hosp Pharm 2000; 35: 57-74.
17. Meggs WJ, Hoffman RS. Fatality resulting from intraventricular vincristine administration. J Toxicol Clin Toxicol 1998; 36: 243-46.