Fatal myeloencephalopathy due to accidental intrathecal vincristin administration: a report of two cases

Dettmeyer, R.; Driever, F.; Becker, Achim; Od, Wiestler; Madea, Burkhard

doi:10.1016/s0379-0738(01)00394-2

Cited by 62 publications

(31 citation statements)

References 27 publications

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“…Once put into practice, these measures seem natural, although they frequently emerged after long discussions. All participants in the haematology conferences were already aware of the well-documented fatal risk of accidental intrathecal injection of vincristine [14,38], but the 2 recent near-miss accidents were reminders that it could still occur. In agreement with other studies, the present report confirms that open discussion of errors and near-miss events may improve error reporting, thereby promoting patient safety [33,34,35].…”

Section: Discussionmentioning

confidence: 99%

“…In oncology, prevention and management of errors are particularly critical because the patients' health status is poor and the drugs employed are toxic, have a low therapeutic index and are susceptible to be implicated in drug-drug interactions [13,14,15,16,17]. Most studies of medication errors in cancer care report high rates of severe events [18,19,20].…”

Section: Introductionmentioning

confidence: 99%

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Improving Cancer Patient Care with Combined Medication Error Reviews and Morbidity and Mortality Conferences

Ranchon¹,

You²,

Salles³

et al. 2013

Chemotherapy

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Background: To reduce the occurrence of medication errors, a systemic approach was developed combining anti-neoplastic medication error reviews and morbidity and mortality conferences (M&MCs). We report the first experience of implementing this strategy in oncology. Methods: The case reports submitted to combined reviews were prepared by physicians and pharmacists, and medication error(s) were described and chronological and root-cause analyses were performed. Results: Ten combined reviews were conducted, which involved the departments of haematology, medical oncology, pneumology, gastroenterology and clinical oncology pharmacy. A total of 91 errors were analysed, of which 3 had reached the patient. Thirty-four corrective actions were proposed; 53% consisted of changes in practice, 35% in procedural reminders and 12% in on-ward education sessions. Conclusions: The combination of medication error reviews and M&MCs appears to be an efficient means of improving cancer patient safety and personnel proficiency. This multidisciplinary work is indispensable to improve future patient management through the critical analysis of past medical errors.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Improving Cancer Patient Care with Combined Medication Error Reviews and Morbidity and Mortality Conferences

Ranchon¹,

You²,

Salles³

et al. 2013

Chemotherapy

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“…In nearly all cases, inadvertent intrathecal administration of vincristine resulted in ascending radiculo-myelo-encephalopathy and death within days or weeks. The mechanism by which this is brought about is through vincristine binding to tubulin and formation of neurofilament aggregates which destroy the dynamic neuronal cytoskeleton of the neurons [9]. Various methods have been tried (e.g.…”

Section: Discussionmentioning

confidence: 99%

Two Fatal Cases of Accidental Intrathecal Vincristine Administration: Learning from Death Events

2015

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We report 2 cases of accidental intrathecal vincristine administration. These injections were scheduled as intravenous injections of vincristine at the same time as other intrathecal drugs were scheduled. The mistakes were recognized immediately after administration, and a lumbar puncture was performed to lavage the cerebrospinal fluid (CSF) immediately after the incident. However, both cases developed progressive sensorimotor and radiculo-myelo-encephalopathy and the patients died 3 and 6 days after the incidents due to decerebration. A number of cases of accidental intrathecal vincristine administration have occurred in recent years in other settings, and we add our events to emphasize the need for a preventative and strictly followed protocol in oncology treatment units to prevent further unnecessary deaths.The best ‘cure' for mistakenly administered vincristine via lumbar puncture is prevention, which can be improved by strict adherence to a comprehensive guideline. Oncologic treatment centers should be aware of this guideline and evaluate their protocol for vincristine administration to prevent future incidents. Based on our past experiences, we strongly recommend ‘time-independent' procedures to prevent this type of incident.

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“…Although known for decades, unintentional intrathecal injections unfortunately occur with great regularity -the last case that became known in Germany was in 2000 and in Great Britain at the beginning of 2001 [20][21][22][23][24][25]. In Great Britain, a constant incidence rate of 3 per 100,000 intrathecal chemotherapies was calculated for the period 1985-2001 (per year approximately one patient died) [26].…”

Section: Unintentional Intrathecal Injections: Vincristine Methotrexmentioning

confidence: 99%

“…Vincristine -often applied on the same day and in syringes of the same size (2 ml) as intrathecal methotrexate or cytarabine in leukaemia protocols -may be mistaken for the latter two drugs. Intrathecal vincristine applications, however, almost always have a lethal outcome (in 85 % of the documented cases) [20]. A confusion of the more concentrated intravenous methotrexate dose (500 mg and higher) with the intrathecal methotrexate dose (15 mg) is also possible.…”

Section: Unintentional Intrathecal Injections: Vincristine Methotrexmentioning

confidence: 99%

Typical Medication Errors in Oncology: Analysis and Prevention Strategies

Müller¹

2003

Oncol Res Treat

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Pharmacotherapy in oncology is complex. It has a small therapeutic range, and is susceptible to errors. Medication errors – especially overdosage – often have serious effects while underdosage entails unnoticed impairment of the therapeutic success. Typical medications and procedures susceptible to errors are described: unintentional intrathecal injections, the application of platinum compounds and anthracyclines, confusion of total and single dose, errors of calculation and preparation, or in operation of infusion pumps. Suitable prevention strategies are standardisation, separation of intrathecal and intravenous chemotherapy, and use of specialized software for planning and calculating chemotherapy, as well as non-punitive notification and recording systems for errors and near-errors in treatment.

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Fatal myeloencephalopathy due to accidental intrathecal vincristin administration: a report of two cases

Cited by 62 publications

References 27 publications

Improving Cancer Patient Care with Combined Medication Error Reviews and Morbidity and Mortality Conferences

Improving Cancer Patient Care with Combined Medication Error Reviews and Morbidity and Mortality Conferences

Two Fatal Cases of Accidental Intrathecal Vincristine Administration: Learning from Death Events

Typical Medication Errors in Oncology: Analysis and Prevention Strategies

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