Intrathecal chemotherapy: potential for medication error

Gilbar, Peter J. (2014) Intrathecal chemotherapy: potential for medication error. Cancer Nursing, 37 4: 299-309. doi:10.1097/NCC.0000000000000108

Author Gilbar, Peter J.
Title Intrathecal chemotherapy: potential for medication error
Journal name Cancer Nursing   Check publisher's open access policy
ISSN 1538-9804
Publication date 2014-07-01
Year available 2014
Sub-type Article (original research)
DOI 10.1097/NCC.0000000000000108
Volume 37
Issue 4
Start page 299
End page 309
Total pages 11
Place of publication Philadelphia, PA, United States
Publisher Lippincott Williams and Wilkins
Language eng
Formatted abstract
Background: The central nervous system is a unique sanctuary site for malignant disease. To ensure optimal disease control, intrathecal (IT) chemotherapy is commonly given in conjunction with standard chemotherapy protocols, thus providing the opportunity for medication errors.

Objective: A systematic review of the current literature on medication errors associated with the administration of IT chemotherapy was conducted.

Methods: English-language literature published from January 1960 through June 2013 was accessed. Case reports, clinical studies, and review articles pertaining to IT medication errors were included in the review. References of all relevant articles were searched for additional citations.

Results: Twenty-two cases of accidental IT overdoses have been reported with methotrexate and 1 with cytarabine. There have been numerous cases of antineoplastic agents intended for administration by the parenteral route being inadvertently given intrathecally. Vincristine has been implicated 31 times (25 deaths), as well as vindesine, asparaginase, bortezomib, daunorubicin, and dactinomycin. This has led to profound toxicity and, commonly, death. Unfortunately, many cases go unrecognized or unreported.

Conclusions: The best method for eliminating the risk of IT medication errors is to develop effective methods of prevention and incorporate them into oncology and hematology practice internationally. Strategies include abolishing the syringe as a method of vinca alkaloid administration and substituting small-volume intravenous bags, and developing novel methods for intraspinal drug administration.

Implications for Practice: The nursing profession is in a unique position to influence change and lead the way in establishing preventative strategies into current practice.
Keyword Intrathecal chemotherapy
Medication errors
Q-Index Code C1
Q-Index Status Confirmed Code
Institutional Status UQ
Additional Notes Publication date July/August 2014

Document type: Journal Article
Sub-type: Article (original research)
Collections: Official 2015 Collection
School of Medicine Publications
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Citation counts: TR Web of Science Citation Count  Cited 2 times in Thomson Reuters Web of Science Article | Citations
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