Preventing intrathecal chemotherapy errors: one institution's experience.

The most commonly reported reason for errors is that a syringe containing a vinca alkaloid is mistaken for a syringe containing an intrathecal medication. Very few medications, including chemotherapeutic agents, can be administered safely into the intrathecal space. Most intrathecal chemotherapy errors involve the accidental injection of vincristine; however, all of the vinca alkaloids (vinblastine, vindesine, vinorelbine, and vincristine) can cause fatal neurologic effects if given intrathecally (World Health Organization, 2007). Although the exact incidence is unknown, the World Health Organization has cited 55 incidents worldwide since 1968. Despite extensive labeling requirements and recommendations, accidental administration of vinca alkaloids into the intrathecal space continues to occur. As recently as 2008, an accidental injection of vindesine led to the death of a 25-yearold man with non-Hodgkin lymphoma (Institute for Safe Medication Practices, 2008). The vinca alkaloids, if given intrathecally, cause rapidly progressing sensory and motor dysfunction, paralysis, encephalopathy, coma, and death (Al Ferayan, Russell, Al Wohaibi, Awada, & Scherman, 1999; Schulmeister, 2004). Central nervous system lesions are those of chemical leptomeningitis and ventriculitis (Al Ferayan et al.). Autopsy findings show loss of neurons, nerve axon degeneration, and myelin loss on the spinal nerves (Dettmeyer, Driever, Becker, Wiestler, & Madea, 2001; Kwack et al., 1999).