It is uniformly fatal and impossible to undo. When the chemotherapy drug vincristine is placed in a syringe and injected intrathecally—into the spinal fluid—the patient always dies. And despite safety guidelines and labels, deaths continue to occur.
Now the National Comprehensive Cancer Network® (NCCN®) has launched a campaign to end even the possibility of this medical error. Just Bag It: the NCCN Campaign for Safe Vincristine Handling encourages health-care providers and institutions always to dilute and administer vincristine in a mini intravenous (IV)-drip bag rather than a syringe, a measure that makes it impossible to administer the drug intrathecally.
Vincristine, which is mainly used to treat leukemias and lymphomas, can be dispensed by hospital pharmacies in either a drip bag or a syringe. Patients being treated with vincristine also receive other agents that are routinely delivered intrathecally and therefore must be in a syringe. When vincristine is also dispensed in a syringe for the same patient, there is the risk that it will be mistakenly injected into the spinal fluid rather than a vein.
In addition, since 2008, the U.S. Food and Drug Administration (FDA) and the Institute for Safe Medication Practices took another step to prevent medication errors with vincristine. In the FDA-approved list of Look-Alike Drug Names With Recommended Tall Man Letters, health-care practitioners are encouraged to refer to vincristine as vinCRIStine to avoid confusing it with vinBLAStine.
Uniformly Fatal Yet Preventable
Robert W. Carlson, MD
Medical errors are not unusual, but this one is unique in being uniformly fatal. And it is not difficult to prevent, said Robert W. Carlson, MD, NCCN’s Chief Executive Officer, who spearheaded the campaign. An IV bag cannot be used intrathecally, so adoption of the Just Bag It policy would eradicate the error, he said, speaking at an NCCN press briefing in Philadelphia.
There have been 125 reported deaths from this medical error since vincristine was approved in the 1960s. The last known death occurred in Argentina in 2015. But many errors go unreported, said Michael R. Cohen, RPh, MS, ScD (hon), PDS (hon), FASHP, President of the Institute for Safe Medication Practices, who also spoke at the press briefing.
Michael R. Cohen, RPh, MS, ScD (hon), PDS (hon), FASHP
One Death Is One Too Many
And regardless of the numbers, if it happens once, it is one too many times, said Dr. Carlson and other speakers.
Robin and Debra Wibeto, who lost their 21-year-old son, Christopher, to this medical error in 2005, have lent their voices to the campaign. They described how “in one instant, everything changed” due to a careless mistake. “When we heard about this campaign, we knew we wanted to do whatever we could to make sure it does not happen again,” Robin said. “If my speaking here could save even one life, it would be beyond worth it,” added Debra Wibeto. “We urge any medical provider who administers vincristine to just bag it.”
Some Progress
Awareness of the problem has grown over the past decade, thanks in part to warning labels instituted by the U.S. Pharmacopeia and the policies of the World Health Organization; the Joint Commission, which accredits hospitals; and the Oncology Nursing Society, as well as the Institute for Safe Medication Practices. The NCCN’s Best Practices Committee, an early advocate, issued recommendations for the safe handling of vincristine in 2008 through its chemotherapy order templates, however, the guidelines for minibag administration were published in July 2016.
It is my hope that every other cancer center in the United States and abroad will follow suit [to adopt the Just Bag It policy].— F. Marc Stewart, MD
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F. Marc Stewart, MD, Co-Chair of the NCCN Best Practices Committee, said that all 27 NCCN member institutions in the United States have adopted the Just Bag It policy. “It is my hope that every other cancer center in the United States and abroad will follow suit,” added Dr. Stewart, who is Acting Division Head of Medical Oncology at the University of Washington and Medical Director of the Seattle Cancer Care Alliance.
According to a survey by the Institute for Safe Medication Practices, the proportion of hospitals requiring IV bags for vincristine has been slowly rising. About 50% of hospitals surveyed reported implementing the recommendation in 2016, compared with 38% in 2014. However, no U.S. agency has the authority to mandate the policy, Dr. Cohen said, and the NCCN campaign is important to further progress.
A Few Barriers
From a health-care provider’s point of view, there seem to be a few barriers to implementing the policy. Use of an IV bag is associated with an increased risk of extravasation (leakage of a drug into tissue near the administration site). But studies show that this risk is extremely low (< 0.5%), Dr. Cohen revealed.
Cost seems unlikely to be a factor, since the price of a mini IV bag is only slightly higher than the price of a syringe. The major reason more hospitals have not adopted the policy appears to be “the age-old habit of putting vincristine in a syringe and not being able to change that habit,” admitted Dr. Cohen.
The NCCN campaign will be working to increase awareness and adoption of the Just Bag It policy in the coming year, partly through communications with the organization’s 27 Member Institutions and other medical professionals in the U.S. and abroad. It has established a website, nccn.org/justbagit, for information on the campaign, including a list of hospitals that have adopted the policy. Hospitals instituting the policy can report their participation through a special section of that website. ■
Disclosure: Drs. Carlson, Stewart, and Cohen reported no potential conflicts of interest.
