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

Abstract

Get full access to this article

View all access options for this article.

References

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: 737-746.

Fischer D , Alfano S , Knobf MT , Donovan C , Beaulieu N. Improving the cancer chemotherapy use process. J Clin Oncol 1996; 14: 3148-3155.

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.

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: 4705-4712.

Schochet SS , Lampert PW , Earle KM. Neuronal changes by intrathecal vincristine sulfate. J Neuropathol Exp Neurol 1968; 27: 645-658.

Dyer C. Doctors suspended after injecting wrong drug into spine. BMJ 2001; 322: 257-258.

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.

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.

Alcaraz A , Rey C , Concha A , Medina A. Intrathecal vincristine: fatal myeloencephalopathy despite cerebrospinal fluid perfusion. J Toxicol Clin Toxicol 2002; 40: 557-561.

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: 587-590.

12.

Lanigan CJ. Safer epidural and spinal connectors. Anaesth 2002; 57: 567-571.

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: 965-965.

14.

Stefanou A , Dooley MJ. In reply. J Clin Oncol 2004; 22: 965-966

15.

Stefanou A , Dooley M. Simple method to eliminate the risk of inadvertent intrathecal vincristine administration (letter). J Clin Oncol 2003; 21: 2044-2047.

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: 243-246.