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Patient Safety

Patient Safety Resources

Medication safety in oncology: Vincristine

Vincristine, a chemotherapy drug used in the treatment of leukemias, lymphomas, and a variety of solid tumors, may cause nerve toxicity. Despite reports for more than 30 years, "wrong route" errors occasionally occur. If delivered intrathecally (injected into the fluid-filled space around the spinal cord), rather than intravenously, the effects are usually fatal.

The Institute for Safe Medication Practices (ISMP) conducted a survey in 2006 that showed the need for better error reduction strategies. The report included a description of correct procedures and a summary of survey results.

IV vincristine survey shows safety improvements needed

Institute for Safe Medication Practices. Feb. 23, 2006.

The Joint Commission issued a Sentinel Event Alert in July 2005 that included a description of Dana-Farber's protocol for the proper handling and dispensing of vincristine.

Preventing vincristine administration errors

The Joint Commission. Sentinel Event Alert. July 14, 2005; Issue 34:1-3.

Vincristine References

Learn more about vincristine safety in these papers, case reports, and alerts:

1. al Fawaz IM. Fatal myeloencephalopathy due to intrathecal vincristine administration. Ann Trop Paediatr 1992; 12:339-342. Abstract
2. Alcaraz A, Rey C, Concha A, et al. Intrathecal vincristine: fatal myeloencephalopathy despite cerebrospinal fluid perfusion. J Toxicol Clin Toxicol 2002; 40:557-561. Abstract
3. Australian Council for Safety and Quality in Health Care. Vincristine can be fatal if administered by the intrathecal route. Medication Alert 2005. PDF
4. Bain PG, Lantos PL, Djurovic V, et al. Intrathecal vincristine: a fatal chemotherapeutic error with devastating central nervous system effects. J Neurol 1991; 238:230-234.
5. Berwick DM. Not again! Bmj 2001; 322:247-248. Full text
6. Bleck TP, Jacobsen J. Prolonged survival following the inadvertent intrathecal administration of vincristine: clinical and electrophysiologic analyses. Clin Neuropharmacol 1991; 14:457-462. Abstract
7. Dettmeyer R, Driever F, Becker A, et al. Fatal myeloencephalopathy due to accidental intrathecal vincristin administration: a report of two cases. Forensic Sci Int 2001; 122:60-64. Abstract
8. Fernandez CV, Esau R, Hamilton D, et al. Intrathecal vincristine: an analysis of reasons for recurrent fatal chemotherapeutic error with recommendations for prevention. J Pediatr Hematol Oncol 1998; 20:587-590. Abstract
9. Gaidys WG, Dickerman JD, Walters CL, et al. Intrathecal vincristine. Report of a fatal case despite CNS washout. Cancer 1983; 52:799-801. Abstract
10. Gilbar PJ, Carrington CV. Preventing intrathecal administration of vincristine. Med J Aust 2004; 181:464. Full text
11. Michelagnoli MP, Bailey CC, Wilson I, et al. Potential salvage therapy for inadvertent intrathecal administration of vincristine. Br J Haematol 1997; 99:364-367. Abstract
12. Schochet SS, Jr., Lampert PW, Earle KM. Neuronal changes induced by intrathecal vincristine sulfate. J Neuropathol Exp Neurol 1968; 27:645-658.
13. Schulmeister L. Preventing vincristine sulfate medication errors:  Oncol Nurs Forum 2004; 31:E90-98. Abstract

For more information, contact Andrew Seger, PharmD, consultant to the Center for Patient Safety and senior reseach pharmacist at Partners' Healthcare. Andrew_Seger@dfci.harvard.edu.