The National Patient Safety Agency (NPSA) has issued guidance on the prescription and administration of vinca alkaloids, a series of intravenous chemotherapy agents, in response to reports of four fatal and serious incidents in which doses of vinca alkaloids intended for intravenous administration were injected in the spine, causing paralysis and death.
• Doses should be prepared and administered in intravenous 50 ml 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 differentiate vinca alkaloid minibags from other minibag infusions.
Chemotherapy procedures should be amended to reflect these requirements and staff alerted. 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 50 ml 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, as this is where the fatalities can occur with wrong route administration.”
