Saturday, July 4, 2015

A preventable cancer drug error that's always fatal

A rare but fatal error can occur when the cancer medicine vincristine is given the wrong way. Vincristine is given intravenously (into the vein) to treat various types of cancer, often in children for leukemia. It is often given in combination with another cancer medicine called methotrexate. Methotrexate can be given into the spinal canal (which is called an intrathecal injection.) This helps prevent the cancer from spreading to the brain. But if vincristine is mistakenly given into the spinal canal instead of methotrexate, which it sometimes is, death is almost certain.

A preventable cancer drug error that’s always fatal

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A rare but fatal error can occur when the cancer medicine vincristine is given the wrong way. Vincristine is given intravenously (into the vein) to treat various types of cancer, often in children for leukemia. It is often given in combination with another cancer medicine called methotrexate. Methotrexate can be given into the spinal canal (which is called an intrathecal injection.) This helps prevent the cancer from spreading to the brain. But if vincristine is mistakenly given into the spinal canal instead of methotrexate, which it sometimes is, death is almost certain.

We recently learned about such an event that happened in 2010 involving an adult woman being treated for lymphoma (a type of cancer). She was supposed to get intravenous vincristine as well as methotrexate into her spinal canal. The vincristine was accidentally given into her spinal canal. The error was noticed right away. The woman was admitted to the hospital and a procedure was done to try to remove the medicine form her spinal fluid. The woman had no complaints until 3 days later. Then, she complained of a headache, weakness in her legs, and hearing loss. She continued to get worse. Over the next two weeks she became unable to move her arms or legs, had trouble breathing, went into a coma, and died. Sadly, this is a typical scenario when this error happens. A slow, agonizing death usually occurs over one to four weeks as the drug slowly but surely destroys the central nervous system (brain and spinal cord).  A New Jersey police chief had this happen several years ago. I also have records of this happening to patients in Pennsylvania and New York.

Since 1968 there have been at least 120 reported cases around the world of vincristine being mistakenly administered into the spinal column. Almost all have resulted in death. In all of these cases, both medicines were put into syringes that looked alike. Most often, the syringes of medicine were prepared in the pharmacy and sent together to the unit where the drugs were to be given – the vincristine to be given intravenously and the methotrexate into the spinal canal. But the syringes of medicine were later mixed up, and the vincristine was accidentally given into the spinal column instead of the methotrexate. 

Although this type of error is rare, it can be easily prevented. Since 2001 my organization has promoted diluting vincristine in a small bag of intravenous fluid (called a minibag) instead of putting it in a syringe. The World Health Organization began supporting this in 2007.  When a nurse, doctor, or other healthcare professional sees the vincristine in a minibag, it is clear that the medicine should be given intravenously. Also, the amount of fluid in the bag makes it nearly impossible to give the medicine into the spinal column.

We have written about this error and how to prevent it many times in our newsletters for healthcare professionals and hospitals and many of them now use this technique. But some are stuck in the old way – still placing it in a syringe. Recently, we received a suggestion from one of our readers to inform consumers about this issue. The reader suggested soliciting your help in preventing this fatal error from occurring.

Here’s what you can do: If you or a family member is receiving treatment for cancer, learn about all the medicines that will be given. Ask for written information about each medicine. Ask for the dose of the medicine and how it will be given. Keep a log of all the medicines that were taken. If one of the medicines is vincristine, we encourage you to request that the medicine be provided in a minibag, not a syringe, to reduce the risk of a fatal error.


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President, Institute for Safe Medication Practices
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Check Up covers regional health news and a wide array of healthcare topics from pharmaceutical happenings to patient safety. Read about some of our bloggers here.

Portions of this blog may also be found in the Inquirer's Sunday Health Section.

Michael R. Cohen, R.Ph. President, Institute for Safe Medication Practices
Daniel R. Hoffman, Ph.D. President, Pharmaceutical Business Research Associates
Hooman Noorchashm, M.D., Ph.D. Cardiothoracic surgeon in the Philadelphia area
Amy J. Reed, M.D., Ph.D. Anesthesiologist and Surgical Intensivist in the Philadelphia Area
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