Global Targeted Medication Safety Best Practice 2

Prepare and dispense vinca alkaloids in a minibag, never in a syringe

Rationale:

Vinca alkaloids (vinblastine, vinorelbine, vinCRIStine) are chemotherapy drugs that should only be administered intravenously and never by any other route (1). Deaths have been reported throughout the world when a vinca alkaloid was dispensed in a syringe but given into spinal fluid instead of intravenously for leukemic patients.

Intrathecal administration of vinca alkaloids leads to the destruction of the central nervous system radiating from the injection site. Essentially, the outcome is always fatal. Even for the few who might survive with immediate spinal fluid washout, devastating neurological damage will likely occur (2). VinCRIStine is particularly problematic, and the most frequently reported drug associated with accidental intrathecal administration, because it is often ordered in conjunction with medications that are administered intrathecally (e.g., methotrexate, cytarabine, and/or hydrocortisone) (2). The World Health Organization (WHO) indicated that between 1968 and 2007, intrathecal administration of vinCRIStine errors had been reported 55 times in a variety of international setting (3). More recently, ISMP reported 135 fatalities involving vinCRIStine in a syringe (4). Despite repeated warnings (“For Intravenous Use Only—Fatal If Given by Other Routes”) and extensive labeling requirements in some countries, accidental administration of vinCRIStine intrathecally still occurs (2,3).

Goal:

The goal of this medication safety practice is to ensure that vinCRIStine and other vinca alkaloids (vinblastine, vinorelbine) are administered by the intravenous route only.

Risk reduction strategies and key improvement

Although patient safety might be improved by the used of neuraxial connectors, such devices are not readily available throughout the world and have not been tested as a preventive measure against accidental administration of vinca alkaloids neuraxially.
Therefore, as a forcing function, an effective vinCRIStine error-prevention strategy is to dilute the drug in a minibag containing a volume too large for intrathecal administration (e.g., 25 mL for pediatric patients and 50 mL for adults). A minibag is also less likely to be confused with other drugs in syringes intended for intrathecal use. There have been no reported cases of accidental administration of a vinca alkaloid by the intrathecal route when dispensed in a minibag (2).

Improving medication safety practices for preparing and dispensing vinca alkaloids (e.g., vinCRIStine, vinblastine, vinorelbine) in a minibag

Globally, many organizations have switched to preparing vinca alkaloids in minibags, overcoming concerns of extravasation (4,5,6,7) and other complications (2), but some organizations still administer vinCRIStine via syringe (1). Results from the 2013 International Medication Safety Self Assessment® for Oncology indicated that 61% of participants had fully implemented the preparation of vinCRIStine in minibags (8).More recent surveys carried out in USA (2017)  and Shanghai (2015) indicate that more than 80% of participants prepare vinCRIStine in minibags (9,10).

The preparation of vinca alkaloids in minibags has been supported in the United-States by The Joint Commission (1), the Institute for Safe Medication Practices (ISMP)(2), Oncology Nurses Society (11), National Comprehensive Cancer Network (12), and elsewhere by the UK National Health Service (NHS)(13), the WHO (3), the ISMP Canada (8), the Australia Commission on Safety and Quality in Healthcare (14), the French Medicines Agency (15), ISMP-España (16) and others.

Indisputably, the best practice to alleviate the risk of this error is to globally adopt the preparation of vinca alkaloids in minibags.

References:

  1. The Joint Commission. Eliminating vincristine administration events. Quick Safety. 2017;37:1-3. Access
  2. ISMP 2018-2019 Targeted Medication Safety Best Practices for Hospital. Best Practice 1. December 12, 2017. Access
  3. World Health Organization. Vincristine (and other vinca alkaloids) should only be given intravenously via a minibag. Information Exchange System, Alert No. 115. July 18, 2007. Download
  4. ISMP. ISMP calls on FDA-No more syringes for vinca alkaloids! ISMP Medication Safety Alert! 2019;24(5): 1-2.
  5. Gilbar P, et al. Medication safety and the administration of intravenous vincristine: international survey of oncology pharmacists. J Oncol Pharm Pract 2015; 21: 10-18.
  6.  Gilbar PJ, Carrington CV The incidence of extravasation of vinca alkaloids supplied in syringes or mini-bags. J Oncol Pharm Pract 2006; 12: 113-118.
  7.  Nurgat ZA, et al. Introduction of vincristine mini-bags and an assessment of the subsequent risk of extravasation. J Oncol Pharm Pract 2015; 21: 339-347
  8. Institute for Safe Medication Practices Canada. Published data supports dispensing vincristine in minibags as a system safeguard. ISMP Canada Safety Bulletin 2001 ; 1(1):1. Download
  9. ISMP 2016-2017 Targeted Medication Safety Best Practices for Hospitals Survey Results. Best Practice 1. July 2017. Download
  10. Yan M, Shen C, Zhang L, et al Vincristine drug safety administration survey: results from hospitals in Shanghai, China Eur J Hosp Pharm 2015; 22: 255-259.
  11. Oncology Nursing Society (US) New recommendations call for bagged vinca alkaloids. November 2016. Access
  12. National Comprehensive Cancer Network (US) Just bag it campaign for safe vincristine handling. Access
  13. National Patient Safety Agency. Rapid Response Report - Using Vinca Alkaloid Minibags (Adult/Adolescent Units). NPSA/2008/RRR04 . August 11, 2008. Download
  14. Australia Commission on Safety and Quality in Healthcare. Vincristine can be fatal if administered by the intrathecal route. Australian Council for Safety and Quality in Health Care Medication Alert! Alert 2. December 2005. Download
  15. French Medicine Agency (Afssaps) Recommendations destinées à prévenir les risques d’erreur d’administration intrathécale de vinca-alcaloïdes 21 May 2007. Access
  16. ISMP-España and GEDEFO. Alerta especial. Errores asociados a la administración de vincristina. ISMP-España and Gedefo. July 2006. Download