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Quick Safety. October 16, 2017;(37):1-3.
Vincristine administration errors can have serious consequences. This newsletter article outlines steps to reduce risks associated with this high-alert medication and spotlights national organizations that have advocated for using minibags to administer vincristine as a safety strategy.
Hyperbilirubinemia Refractory to Phototherapy
Vinod K. Bhutani, MD, and Ronald J. Wong
The Forgotten Radiographic Read
Clinton J. Coil, MD, MPH, and Mallory D. Witt, MD
Mitigating errors caused by interruptions during medication verification and administration: interventions in a simulated ambulatory chemotherapy setting.
Prakash V, Koczmara C, Savage P, et al. BMJ Qual Saf. 2014;23:884-892.
Medication safety and the administration of intravenous vincristine: international survey of oncology pharmacists.
Gilbar P, Chambers CR, Larizza M. J Oncol Pharm Pract. 2015;21:10-18.
Understanding and managing IV container overfill.
ISMP Medication Safety Alert! Acute Care Edition. November 14, 2013;18:1-4.
Death and neurological devastation from intrathecal vinca alkaloids: prepared in syringes = 120; prepared in minibags = 0.
ISMP Medication Safety Alert! Acute Care Edition. September 5, 2013;18:1-4.
Chemotherapy in home care: one team's performance improvement journey toward reducing medication errors.
Ewen BM, Combs R, Popelas C, Faraone GM. Home Healthc Nurse. 2012;30:28-37.
Fatal consequences of a simple mistake: how can a patient be saved from inadvertent intrathecal vincristine?
Reddy GK, Brown B, Nanda A. Clin Neurol Neurosurg. 2011;113:68-71.
Checking it twice: an evaluation of checklists for detecting medication errors at the bedside using a chemotherapy model.
White RE, Trbovich PL, Easty AC, Savage P, Trip K, Hyland S. Qual Saf Health Care. 2010;19:562-567.
Chemotherapy patients' perceptions of drug administration safety.
Schwappach DLB, Wernli M. J Clin Oncol. 2010;28:2896-2901.
Interruptions during the delivery of high-risk medications.
Trbovich P, Prakash V, Stewart J, Trip K, Savage P. J Nurs Adm. 2010;40:211-218.
The quest to eliminate intrathecal vincristine errors: a 40-year journey.
Noble DJ, Donaldson LJ. Qual Saf Health Care. 2010;19:323-326.
American Society of Clinical Oncology/Oncology Nursing Society chemotherapy administration safety standards.
Jacobson JO, Polovich M, McNiff KK, et al; American Society of Clinical Oncology; Oncology Nursing Society. Oncol Nurs Forum. 2009;36:651-658.
Medication errors in chemotherapy: incidence, types and involvement of patients in prevention. A review of the literature.
Schwappach DLB, Wernli M. Eur J Cancer Care (Engl). 2009;19:285-292.
Medication errors among adults and children with cancer in the outpatient setting.
Walsh KE, Dodd KS, Seetharaman K, et al. J Clin Oncol. 2009;27:891-896.
Vincristine: Learning from Error Workshop.
World Alliance for Patient Safety. Geneva, Switzerland: World Health Organization; 2008.
Fluorouracil Incident Root Cause Analysis Report.
Toronto, ON, Canada: Institute for Safe Medication Practices Canada. April 30, 2007.
Using Failure Mode and Effects Analysis for safe administration of chemotherapy to hospitalized children with cancer.
Robinson DL, Heigham M, Clark J. Jt Comm J Qual Patient Saf. 2006;32:161-166.
IV vincristine survey shows safety improvements needed.
ISMP Medication Safety Alert! Acute Care Edition. February 23, 2006;11:1-2.
Fatal misadministration of IV vincristine.
ISMP Medication Safety Alert! Acute Care Edition. December 1, 2005;10:1-2, 4.
Preventing vincristine administration errors.
The Joint Commission. Sentinel Event Alert. July 14, 2005;(34):1-3.
Berwick DM. BMJ. 2001;322:247-248.
When a nurse is prosecuted for a fatal medical mistake, does it make medicine safer?
Gordon M. Health Shots. National Public Radio. April 10, 2019.
The effect of a residential care pharmacist on medication administration practices in aged care: a controlled trial.
McDerby N, Kosari S, Bail K, Shield A, Peterson G, Naunton M. J Clin Pharm Ther. 2019 Feb 21; [Epub ahead of print].
Using a spare medication vial to store multiple medications: a potentially fatal in-home medication error.
Leonard JB, Klein-Schwartz W. Am J Health Syst Pharm. 2019;76:264-265.
PSNET: Patient Safety Network
PSNet is produced for the Agency for Healthcare Research and Quality by a team of editors at the University of California, San Francisco with guidance from a prominent Technical Expert/Advisory Panel. The AHRQ PSNet site was designed and implemented by Silverchair.
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