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Some treatments are injected into the fluid around the spine (intrathecal chemotherapy). Vincristine and related drugs, given into a vein, are fatal if injected there by mistake. Hospitals prevent this by keeping spinal chemotherapy separate in time and place, using only trained and registered staff, double checking with you, and giving vincristine from a small drip bag rather than a syringe.
Vinca alkaloids (vincristine, vinblastine, vindesine, vinorelbine) cause paralysis and almost always death if injected intrathecally; HSC 2008/001 cites 55 such incidents worldwide. The safeguards are of two kinds. First, intrathecal chemotherapy is separated: ASCO-ONS (2024, standard 3.13) requires it to be prepared separately, uniquely labelled, stored and delivered apart from other chemotherapy, and given immediately after a time out with a two-practitioner double check. England's HSC 2008/001 goes further: a register of trained and authorised staff for every task (prescribing, dispensing, issuing, checking, administering), issue only after written confirmation that the day's intravenous chemotherapy has been given (paediatric exceptions), a separate room with walls and a door used for nothing else in that session, a check by a second registered person and the patient if they wish, and normal working hours.
Second, intravenous vinca alkaloids are given only by infusion from a minibag, never a syringe. ISMP Best Practice 1 applies this in every setting, and ISMP does not accept large-volume syringes as an alternative; ASCO-ONS requires it where intrathecal chemotherapy is given; the NPSA alert of 2008 applied it to adult and adolescent units and not to paediatric units. Extravasation was similarly rare with syringes and minibags (0.03% and 0.04% in an Australian study cited by ISMP).
Why: Most fatal errors happened when someone unfamiliar with the process gave the injection.
“A register should be established and maintained which lists designated personnel who have been trained and authorised to prescribe, dispense, issue, check or administer intrathecal chemotherapy”
Why: Physical separation stops an intravenous syringe being picked up by mistake.
“Labeled immediately after preparation with a uniquely identifiable label for intrathecal or intraventricular medication”
ASCO and the Oncology Nursing Society (JCO Oncology Practice) 2024
Why: If the intravenous drugs are already in the patient, there is nothing left to mix up.
“Intrathecal chemotherapy drugs should be issued at a different time from drugs for intravenous chemotherapy. Intravenous chemotherapy drugs should be issued first.”
Why: A curtained bay next to an intravenous chemotherapy chair is where mix-ups happen.
“This area should be a separate room (ie. with walls and a door). A curtained off area with a sign is not a suitable alternative.”
Why: A second trained person, and the patient, checking drug, dose and route catch the wrong syringe.
“These checks should include a member of staff (not the member of staff who will be administering the ITC on that occasion) appropriately trained, deemed competent and on the register to carry out this check, the patient and, if appropriate, a relative or guardian.”
Why: The record shows each check happened and by whom.
“The checks made should be recorded.”
Why: A minibag cannot be connected to a spinal needle, so the fatal wrong-route error becomes impossible.
“BEST PRACTICE 1: Dispense vinCRIStine and other vinca alkaloids in a minibag of a compatible solution and not in a syringe.”
Why: Wrong-route errors have still happened with diluted doses in syringes.
“ISMP does not recommend the use of large volume syringes as an acceptable alternative to the minibag.”
Why: The two procedures meet in the same units, so the rule must be part of the intrathecal policy.
“The health care organization that administers antineoplastic therapy directly into the cerebral spinal fluid has policy that specifies that intravenous vinca alkaloids are administered only by infusion, for example, mini bags”
ASCO and the Oncology Nursing Society (JCO Oncology Practice) 2024
How care is usually carried out, read from the guidelines and standards cited. Your own team's protocol and their judgement come first; this page is for understanding it, not for doing it yourself.
Separate intrathecal chemotherapy in time, place and people: a register of authorised staff, separate preparation and labelling, issue only after the day's intravenous chemotherapy, a dedicated room, and a recorded double check with the patient (HSC 2008/001; ASCO-ONS 2024 standard 3.13), and give every intravenous vinca alkaloid from a minibag, never a syringe (ISMP Best Practice 1, all settings). The sources differ on scope: ISMP applies minibags wherever vincristine is given, ASCO-ONS requires the policy where intrathecal chemotherapy is given, and the NPSA alert of 2008 applied it to adult and adolescent units but not paediatric units. None of these standards is graded.
Department of Health (England) 2008 · ASCO and the Oncology Nursing Society (JCO Oncology Practice) 2024 · Institute for Safe Medication Practices (ECRI) 2026 · National Patient Safety Agency (England) 2008
Where it differs: Paediatric units give vincristine by syringe, relying on intrathecal separation and checks rather than minibags.
Evidence: The NPSA alert (2008) states it does not apply to children and teenagers treated in a paediatric unit, where minibags were not being recommended. ISMP (2026) applies Best Practice 1 in every setting, and its FAQ describes back-flushing a minibag line for adults and children to limit drug left in tubing.
National Patient Safety Agency (England) 2008 · Institute for Safe Medication Practices (ECRI) 2026
| Recommendation | Grade, as printed | Source |
|---|---|---|
| Intrathecal drugs administered immediately after a time out and two-practitioner double check “Administered immediately after a time out, double check procedure that involves two licensed practitioners or other licensed clinicians approved by the health care organization to prepare or administer antineoplastic therapy” | Standard (not graded) | ASCO and the Oncology Nursing Society (JCO Oncology Practice) 2024 |
| Vinca alkaloids by minibag, not syringe, in every patient care setting “For example, the Best Practice 1 related to vinCRIStine should be implemented in whatever patient care setting this treatment is provided.” | ISMP Targeted Medication Safety Best Practice (not graded) | Institute for Safe Medication Practices (ECRI) 2026 |
| Minibag alert applies to adult and adolescent units only “It does not apply to children and teenagers being treated in a paediatric unit where minibags are not being recommended to administer vinca alkaloids.” | NPSA rapid response report (not graded) | National Patient Safety Agency (England) 2008 |
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