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The prevention of intrathecal medication errors: a report to the Chief Medical Officer

Administration of Vinca alkaloids such as vincristine by the spinal route, rather than intravenously, invariably causes death or neurological damage. This catastrophic clinical error has arisen because of confusion of the drug with a cytotoxic agent intended to be given intrathecally (usually methotrexate). Five such incidents have occured in NHS hospitals in the past decade, representing an estimated rate of about three per 100,000 intrathecal chemotherapy treatments. This report adopts a systems approach to identify factors which have contributed to these errors and explores safety measures to reduce risk. Recommendations are made for an immediate action plan, implemented by national guidance and reinforced by clinical governance. Key elements are: formal designation within each Trust of medical staff competent to give intrathecal chemotherapy; steps to ensure that intrathecal and intravenous cytotoxic drug treatments are given at different times, by different people and in different clinical locations. Cites 10 references [Book abstract]