NCCN launches ‘Just Bag It’ campaign to prevent deadly medical error in vincristine administration

The National Comprehensive Cancer Network today launched a “Just Bag It” campaign to promote safe vincristine administration.

“Just Bag It: The NCCN Campaign for Safe Vincristine Handling” is designed to encourage health care providers to adopt and implement a policy to dilute and administer vincristine in a mini IV–drip bag to prevent deadly medical error.

“It’s really important that we realize that these avoidable medical errors are not just a statistic,” Robert W. Carlson, MD, CEO of NCCN, said during a news conference. “What is important about them is that they impact people in a very strong and negative way.”

Vincristine — a chemotherapy agent typically used to treat leukemia and lymphoma — is intended to block the growth of cancer by preventing cells from separating.

However, it also is a neurotoxin that may cause peripheral neuropathy, if given intravenously, as well as neurotoxicity, if given into the spinal fluid. Vincristine is sometimes combined in a regimen that may include other chemotherapy drugs that are administered intrathecally, which could result in mistaken administration into the spinal fluid leading to ascending paralysis, neurological defects and eventually death.

“The mistake fortunately does not happen often, but if it happens once, it’s too many times because it is a fatal medical error,” Carlson said.

To ensure vincristine is administered properly, the NCCN issued guidelines to dilute and administer the agent in a mini IV–drip bag and to never use a syringe to administer the medication.

“This precaution renders it impossible to accidentally administer the medication into the spinal fluid and greatly decreases the chances of improper dosage,” Carlson added.

In 2008, the NCCN Best Practices Committee published Chemotherapy Order Templates — which detail the most common regimens for various cancers and highlight safety parameters. Among these templates, the NCCN’s policy of vincristine administration is now called out in the safety parameters for the treatment of large cell lymphoma.

“These resources allow practitioners to standardize patient care, reduce medication errors, and anticipate and manage adverse events,” F. Marc Stewart, MD, co-chair of NCCN’s Best Practices Committee, said. “We feel this is a sound recommendation because it eliminates the ability to administer the drug incorrectly.”

All 27 NCCN member institutions have adopted these guidelines, and additional organizations — such as Institute for Safe Medication Practices (ISMP), The Joint Commission, WHO and Oncology Nursing Society — have issued similar recommendations.

However, ISMP–issued surveys indicated that only half of all respondents have implemented this policy into their treatment settings.

“We still have a long way to go. We have had some improvement over the last few years and we’ve had other improvements that have helped to prevent some of these errors, but unfortunately they still go on, and we don’t know when the next one is going to come,” Michael R. Cohen, RPh, MS, ScD (hon), DPS (hon), FASHP, co-founder and president of ISMP, said.

In addition, the policy should be adopted globally, Cohen said.

“We hope that the ‘Just Bag It’ campaign will help in converting all of the hospitals and cancer centers that use IV vincristine, and perhaps intrathecal therapy as well, to do this,” he said. “I think it needs to be taken care of not just in North America, but also globally.” – by Kristie L. Kahl

For more information:

Just Bag It: NCCN campaign for safe vincristine handling. Available at: www.nccn.org/justbagit. Accessed on Nov. 10, 2016.