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NPSA alerts healthcare workers to new guidance for injecting adults and adolescent patients with intravenous cancer drug

11 August 2008

 

The National Patient Safety Agency (NPSA) has issued a Rapid Response Report to healthcare professionals in England and Wales containing guidance on the prescription, distribution and administration of vinca alkaloids, a series of intravenous chemotherapy agents.

 

This is in response to four recent reports of fatal and serious incidents from hospitals outside the UK in which doses of vinca alkaloids intended for intravenous administration were injected in the spine, causing paralysis and death.

 

Previous guidance for the NHS in England and Wales was to dilute doses of vinca alkaloids to 10ml or greater in a syringe in order to reduce the risk of wrong route errors. However there were still incidents reported outside of the UK.  The NPSA is therefore updating current guidance following the learning from these incidents in other countries.

 

The NPSA now recommends that when vinca alkaloids are prescribed, dispensed or administered in adult and adolescent chemotherapy units: 

 

  • Doses should be prepared and administered in intravenous 50ml minibags to minimise the risk of “wrong route” errors.

  • Doses in syringes should no longer be used.

  • The following warning should be prominently displayed on the label of all vinca alkaloid doses – “For Intravenous Use Only – Fatal If Administered by Other Routes”.

  • The colour and design on the label, outer packaging and delivery bags should be well thought-out to differentiate vinca alkaloid minibags from other minibag infusions.

  • Chemotherapy policies and procedures should be amended to reflect these requirements and staff should be alerted to these recommendations and trained accordingly.

 

Speaking of the new Rapid Response Report, Professor David Cousins, Head of Safe Medication Practice and Medical Specialities at the NPSA, said:

 

“Vinca alkaloids have been administered intravenously in 50ml minibags for several years now outside of the UK and so far there have been no reported incidents of wrong route errors. Clinical staff should therefore refrain from injecting vinca doses in syringes to adult and teenage patients in adult and adolescent chemotherapy units, as this is where the fatalities can occur with wrong route administration.”

 

View the Rapid Response Report.

 


 

 

Notes for editors:

 

Media enquiries to Paul Cooney in the NPSA Communications Department on 020 7927 9351 / paul.cooney@npsa.nhs.uk or Sara Coakley on 020 7927 9580 /   sara.coakley@npsa.nhs.uk.

 

 

Vinca alkaloids are anti-cancer drugs which can inhibit cancer growth by stopping cell division and are intended for intravenous administration only.

 

The NPSA Rapid Response Report applies to the use of the vinca alkaloids vincristine, vinblastine, vindesine and vinorelbine in adult and teenage patients being treated in adult and adolescent chemotherapy units. The guidance does not apply to children and teenagers being treated in paediatric units due to the practical difficulties of preparing and administering the infusions intravenously.

 

In July 2007 the WHO World Alliance For Patient Safety issued Alert 115 describing four recent patient safety incidents in different countries in which vincristine had been accidentally administered by intrathecally instead of via the intravenous route. The Alert indicated that since 1968 the same error had been reported 55 times from a variety of institutional settings. These incidents had occurred despite repeated warnings of the risk and introduction of extensive labelling requirements and recommendations intended to standardise practice and reduce risks.

 

Rapid Response Reports

Since June 2007, the NPSA has been issuing notices with supporting information to NHS organisations about risks to patients. These are called Rapid Response Reports and ten have been issued to date.  These are issued to all NHS organisations in England and Wales, presenting the evidence of harm to patients and identifying clear actions to reduce risks.

 

Safer Design

Safer Design is a vital part of improving patient safety.  The National Patient Safety Agency is involved in a series of initiatives to facilitate safer design in several areas of health care. This most recent booklet in the series, “Design for patient safety: A guide to labelling and packaging of injectable medicines”, was released in 2008.

 

The National Patient Safety Agency encompasses the National Research Ethics Service, Patient Safety Division and the National Clinical Assessment Service. Our vision is to lead and contribute to improved, safe patient care by informing, supporting and influencing healthcare individuals and organisations. Each division works within its sphere of expertise to improve patient outcomes.