Journal Article
Commentary

Two fatal cases of accidental intrathecal vincristine administration: learning from death events.

Chotsampancharoen T; Sripornsawan P; Wongchanchailert M.

Incorrectly administered vincristine can lead to serious adverse consequences. Discussing two incidents involving accidental intrathecal vincristine administration, this commentary describes how the health care organization implemented changes (including using different bags for drugs and label colors for syringes) following the first event and made further revisions when the second incident occurred 7 years later (such as ensuring drugs are delivered during different times and in certain settings).