JCAHO Issues Warning on Cancer Medication
The Joint Commission on Accreditation of Healthcare Organizations issued a safety alert Thursday warning hospitals of a rare but serious drug mix-up in which a cancer drug that is supposed to be administered intravenously is injected into spinal catheters, causing permanent paralysis or death in most cases, AP/Long Island Newsday reports.
Vincristine, which is administered to leukemia and lymphoma patients, sometimes mistakenly is added to spinal catheters that are used to administer other cancer drugs. Vincristine kills nerve cells and improper administration often results in death, Andrew Seger, a research pharmacist at the Dana-Farber Cancer Institute, said.
JCAHO, which accredits more than 4,500 hospitals, has received only one report of such an error at a U.S. hospital. However, the alert noted that the mistakes are probably underreported, adding that hospitals are likely "choosing not to voluntarily report these fatal errors to JCAHO" out of fear of lawsuits.
The Institute for Safe Medication Practices has received voluntary reports on six U.S. cases in 30 years, according to ISMP President Michael Cohen. Seger's research has found 49 cases worldwide since 1968, about 90% of which were fatal.
JCAHO said hospitals should ensure that vincristine syringes have labels warning that the drug is for intravenous use only and can be fatal when administered through spinal catheters.
The alert also recommended that hospitals administer vincristine at different times and locations than drugs administered through spinal catheters (Tanner, AP/Long Island Newsday, 7/14).