What’s New in the Patient Safety World
June 2017
Just Bag It Campaign Success Story
We described NCCN’s
“Just Bag It!” campaign in our December 2016 What's New in the Patient Safety
World column “Standardize
4 Safety and Just Bag It!”. The campaign
was launched last year 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.
Researchers from Johns Hopkins presented a poster (Olsen 2017) at the recent Oncology Nursing Society 42nd Annual Congress as described in an NCCN press release (NCCN 2017). Olsen and colleagues described barriers to standardizing vincristine administration in mini-IV drip bags. They noted that many nurses believed the risk of extravasation would be higher when administering via min-bag than when pushing the agent. However, they found zero cases of extravasation among the more than 1,300 mini-bag administrations of vincristine after the practice change.
Instead of pushing the medication through a syringe, in the new technique the nurse holds the mini-bag as it runs through the side port of a free flowing line. 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.
We hope that all sites administering vincristine, not just NCCN member institutions, will use the techniques that are part of the Just Bag It! Campaign. Following the recommendations in the Olsen study should help you in your implementation.
References:
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
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
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
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