Vincristine, a widely used chemotherapeutic agent, should only be administered intravenously, and never by any other route. Many patients receiving intravenous vincristine also receive other medication via a spinal route as part of their treatment protocol. This has led to errors where vincristine has been administered via a spinal route.
Following a death due to intrathecal vincristine in July 2007, WHO issued the following alert:
The WHO World Alliance for Patient Safety has consulted expert opinion widely and recommends the following actions be taken:
- The labelling of vincristine should include a clear warning label that reads: ‘FOR INTRAVENOUS USE ONLY - FATAL IF GIVEN BY OTHER ROUTES’.
- Syringes should not be used for vincristine administration.
- Vincristine should where possible be prepared by dilution in small volume intravenous bags (the ‘minibag’ technique), rather than in a syringe, to protect against accidental administration via a spinal route.