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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-year-old man with non-Hodgkin lymphoma (Institute for Safe Medication Practices, 2008).
The vinca alkaloids, if given intrathe- cally, 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).
Process Problems
The most commonly reported reason for errors is that a syringe containing a vinca alkaloid is mistaken for a syringe containing an intrathecal medication (Schulmeister, 2004; World Health Organization, 2007). In such instances, the practitioners failed to verify the correct medications prior to administering them to patients. Many of the patients had leukemia or lymphoma, and their treatment regimens included intrathecal methotrexate (or cytarabine) and IV vincristine. Both the intrathecal medications and the IV vincristine were mixed in small syringes with approximately 3-5 ml total volume. In some cases, the syringes were sitting next to each other. A previous recommendation to prevent intrathecal chemotherapy errors is to dilute vinca alkaloid medications in larger volumes in syringes, such as 10-20 ml, to prevent confusion between syringes with the same volume. However, despite difference in syringe sizes, errors still occur (World Health Organization). Other reported problems include mislabeling of syringes and lack of knowledge about intrathecal chemotherapy by practitioners administering the medication (Schulmeister; World Health Organization). Although most errors occurred when medication was given by lumbar puncture, similar errors have occurred when vinca alkaloids were given into ventricular reservoirs (e.g., Ommaya reservoirs) (Meggs & Hoffman,...