Mixups in Administering Chemotherapy Drug Lead to Deaths

[NRSKarenRN, BSN, RN]

mixups in administering chemotherapy drug lead to deaths

patients undergoing chemotherapy to fight leukemia and lymphoma are sometimes being accidentally injected with a powerful cancer-fighting drug in an incorrect way that results in death or permanent paralysis, according to an alert issued today by the joint commission on accreditation of healthcare organizations.

the drug vincristine has been widely and successfully used to treat cancer for many years, but the joint commission's sentinel event alert patient safety newsletter reports that the drug is sometimes mistakenly administered in the sac around the spinal cord ("intrathecal") instead of intravenously. the joint commission reports that the intrathecal injection of vincristine can be the result of a single error or a series of mistakes in a medication system.

to reduce the risk of "wrong-route" errors involving vincristine, the joint commission's sentinel event alert newsletter recommends that health care organizations:

• dilute the drug in such volume that it prevents intrathecal administration.

  
  

  
  

• clearly label all vincristine syringes with the warning: "fatal if given intrathecally. for iv use only. do not remove covering until moment of injection."

  
  

  
  

• prevent intravenous (iv) and intrathecal medications from being dispensed or administered at the same time, in the same place, ensuring rather that these two distinct procedures are carried out at different times and locations.

  
  

  
  

• have at least two caregivers conduct a "time out" before the patient receives vincristine to independently confirm the correct patient, the correct drug, the correct dose, and the correct route for administering the drug.

  
  

  
  

the warning about chemotherapy medication errors is the latest in a series of alerts issued by the joint commission, which maintains a comprehensive database of adverse events, and their underlying causes. this database permits the joint commission to warn facilities about dangers in the provision of health care and share solutions to prevent medical tragedies. previous alerts have focused on wrong-site surgery, deadly medication mix-ups, health care-associated infections, and patient suicides, among other issues. the complete list and text of past issues of sentinel event alert can be found on the joint commission website at

www.jcaho.org.

[Geeg]

HMMMMM. two nurses should check the dose, see it always goes back to too few nurses resulting in pt mortality/morbidity.

[Fonenurse]

HMMMMM. two nurses should check the dose, see it always goes back to too few nurses resulting in pt mortality/morbidity.

This sort of error was being reported way back in 2001 in the UK, why have we not learned? See link http://bmj.bmjjournals.com/cgi/content/full/322/7281/257

In an oncology unit where I worked we all had to be specially trained to give this type of chemo and it was only allowed to be administered by extra specially trained doctors. This should not still be happening!!!