WHO Warns about Fatal Errors with Vincristine

Posted on April 29, 2008

The World Health Organization (WHO) is alerting health professionals that despite repeated warnings, patient deaths continue to occur when the chemotherapy drug vincristine, which is intended for IV use, is accidentally given intrathecally. Patients on the receiving end of these accidents have died slowly and painfully.

WHO says that the "gold standard" in preventing these errors is to develop a lock-and-key design for needles, syringes, catheters, tubing and bags. This can prevent medications intended for IV use from being administered intrathecally, and vice versa. In the absence of a lock and key system, WHO recommends diluting IV vincristine and delivering it only in minibags, rather than in syringes. When diluting vincristine, use only normal saline or glucose in water, because vincristine is pH-sensitive. WHO says that vincristine labels should include a warning that says, "For intravenous use only. Fatal if given by other routes."

Additional Information:

World Health Organization. Information Exchange System, Alert #115: Vinicristine. July 18, 2007.
http://www.who.int/medicines/publications/drugalerts/Alert_115_vincristine.pdf

ISMP Medication Safety Alert! – “WHO: Dilute Vincristine in a Minibag”. Volume 12, Issue 15. July 26, 2007.
http://www.ismp.org/Newsletters/acutecare/articles/20070726_1.asp

ISMP Medication Safety Alert! - “IV Vincristine Survey Shows Safety Improvements Needed”. February 23, 2006.
http://www.ismp.org/Newsletters/acutecare/articles/20060223.asp

ISMP Medication Safety Alert! - “Fatal Misadministration of IV Vincristine”. December 1, 2005.
http://www.ismp.org/Newsletters/acutecare/articles/20051201.asp