What’s New in the Patient Safety World

January 2018

Eliminating Vincristine Administration Events

 

 

We highlighted NCCN’s “Just Bag It!” campaign in our What's New in the Patient Safety World columns for December 2016 “Standardize 4 Safety and Just Bag It!” and June 2017 “Just Bag It Campaign Success Story”. Now the Joint Commission has jumped on board, recommending similar measures to reduce vincristine administration errors (TJC 2017).

 

You’ll recall that the “Just Bag It!” campaign was launched in 2016 by the National Comprehensive Cancer Network (NCCN 2016). Vincristine is a chemotherapy agent intended for intravenous use. Yet since the 1960’s there have been numerous incidents where it has been administered intrathecally or via Omaya reservoirs. The results are disastrous, with patients developing quadriplegia, encephalopathy, and usually death. In 2013 ISMP summarized the literature (ISMP 2013) and noted that virtually all cases involved vincristine being prepared in a syringe and that there were no cases when vincristine was prepared in an IV bag. There are, of course, other contributing factors in such incidents. ISMP noted the following contributing factors: mislabeling of syringes; bringing IV and intrathecal medications into a treatment area together; failing to administer vinca alkaloids in a specialty oncology unit or with only experienced, oriented staff familiar with current operational and clinical standards, procedures, or protocols; administering chemotherapy outside of normal hours; not conducting an independent double check or “time out” before intrathecal medication administration; and incomplete or missing warning labels. But, given that all reported incidents occurred when vincristine was in a syringe, ISMP recommended that vincristine instead by diluted in a minibag for infusion and syringes be avoided.

 

The Just Bag It! campaign calls for health care professionals to always dilute vincristine in a 50ml mini-IV drip bag and never in a syringe. The campaign comes with Christopher’s Story, the sad story of a patient who died as the result of one of the above vincristine errors. All NCCN member institutions have already adopted this best practice for handling vincristine but the campaign calls on all other oncology providers to do the same.

 

Our June 2017 What's New in the Patient Safety World column “Just Bag It Campaign Success Story” highlighted how Johns Hopkins nurses successfully implemented the “Just Bag It!” campaign (Olsen 2017, NCCN 2017). Understanding the rationale for the new practice and becoming familiar with the technique were critical. Nurses received training that included background on the reasons for the switch, watched a video of the technique, and had hands-on training in a skills lab to ensure proper technique before going live with this practice change.

 

The new Joint Commission “Quick Safety Issue” (TJC 2017) cites a 2015 international survey of oncology pharmacy practitioners that was conducted to determine how vincristine is administered and the strategies in place for preventing accidental intrathecal administration of vincristine. That survey (Gilbar 2015) revealed that intravenous vincristine was dispensed in minibags in 77.4 percent of centers, though some also used syringes. Syringes were used in 31.1 percent of centers, with half these doses prepared undiluted. The most common reasons for still using syringes were perceived risk of extravasation and faster infusion time. Despite numerous vincristine administrations, extravasation was very rare.

 

The Joint Commission urges hospitals and other health care organizations that provide chemotherapy services to promote the safe administration of intravenous vincristine and other vinca alkaloids by:

 

Inadvertent intrathecal administration of vincristine or vinca alkaloids has devastating results. The interventions described above are extremely important in your efforts to avoid such accidents.

 

 

Our prior columns related to chemotherapy safety:

 

 

 

References:

 

 

TJC (The Joint Commission). Quick Safety Issue 37: Eliminating vincristine administration events. October 2017

https://www.jointcommission.org/issues/detail.aspx?Issue=W%2baIHHqu5280CG6GS0zrd%2bFc6BMqOKeqkXo2se0ydvA%3d

 

 

NCCN (National Comprehensive Cancer Network). Just Bag It: The NCCN Campaign for Safe Vincristine Handling. NCCN 2016; accessed November 14, 2016

https://www.nccn.org/justbagit/

 

 

ISMP (Institute for Safe Medication Practices). Death and neurological devastation from intrathecal vinca alkaloids: Prepared in syringes = 120; Prepared in minibags = 0. ISMP Medication Safety Alert! Acute Care Edition. September 5, 2013

https://www.ismp.org/newsletters/acutecare/showarticle.aspx?id=58

 

 

Olsen M, Benani D, Przybylski A, Carrol S, Szabo K. Putting an Old Oncology Nursing Practice to Bed: A Hospital-Wide Initiative Using Evidence-Based Practice to Standardize the Administration of Vinca Alkaloids Using a Minibag, Side-Arm Technique. Oncology Nursing Society 42nd Annual Congress. Poster 187. May 5, 2017

http://epo.epostersonline.net/ons2017/node/863

 

 

NCCN (National Comprehensive Cancer Network). In Oncology Nursing, One Small Change Can Potentially Prevent Deadly Medical Error in Thousands of Patients. Press Release May 1, 2017

https://www.nccn.org/about/news/newsinfo.aspx?NewsID=872

 

 

Gilbar P, Chambers CR, Larizza M, et al. Medication safety and the administration of intravenous vincristine: International survey of oncology pharmacists. Journal of Oncology Pharmacy Practice 2015; 21(1): 10-18

http://journals.sagepub.com/doi/abs/10.1177/1078155213517729?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dpubmed

 

 

 

 

 

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