Two Fatal Cases of Accidental Intrathecal Vincristine Administration: Learning from Death Events

Abstract

We report 2 cases of accidental intrathecal vincristine administration. These injections were scheduled as intravenous injections of vincristine at the same time as other intrathecal drugs were scheduled. The mistakes were recognized immediately after administration, and a lumbar puncture was performed to lavage the cerebrospinal fluid (CSF) immediately after the incident. However, both cases developed progressive sensorimotor and radiculo-myelo-encephalopathy and the patients died 3 and 6 days after the incidents due to decerebration. A number of cases of accidental intrathecal vincristine administration have occurred in recent years in other settings, and we add our events to emphasize the need for a preventative and strictly followed protocol in oncology treatment units to prevent further unnecessary deaths. The best ‘cure' for mistakenly administered vincristine via lumbar puncture is prevention, which can be improved by strict adherence to a comprehensive guideline. Oncologic treatment centers should be aware of this guideline and evaluate their protocol for vincristine administration to prevent future incidents. Based on our past experiences, we strongly recommend ‘time-independent' procedures to prevent this type of incident.