Cancer drug mix-up can be deadly

Accrediting group warns hospitals about rare, underreported case

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updated 3:43 p.m. ET July 25, 2005

CHICAGO - A rare but probably underreported drug mix-up involving a potent cancer drug can kill or permanently paralyze patients, and hospitals need to take precautions to avoid it, a health care accrediting group warned Thursday.

The drug vincristine is supposed to be injected into a vein but is sometimes accidentally added to spinal catheters used for different drugs in leukemia and lymphoma patients, the Joint Commission on Accreditation of Healthcare Organizations said in a safety alert.

Administering vincristine into the spine kills nerve cells and is usually fatal, said Andrew Seger, a research pharmacist at Boston's Dana-Farber Cancer Institute.

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Seger said his research has found about 49 cases of vincristine mix-ups worldwide since 1968. About 90 percent of patients died, he said.

JCAHO's warning was sent to more than 4,500 hospitals the group accredits. Those that don't follow JCAHO's recommendations for avoiding the mix-up could risk losing accreditation.

Only one U.S. case, resulting in permanent paralysis, has been reported to JCAHO. The Institute for Safe Medication Practices has received voluntary information from doctors about six U.S. cases in 30 years, said Dr. Michael Cohen, institute president.

The most recent cases include the 2002 death of a 49-year-old New Jersey man while undergoing treatment for lymphoma.

Media reports suggest there may be others, raising concern that health care organizations "are choosing not to voluntarily report these fatal errors to JCAHO" out of fear of being sued, the JCAHO alert said.

It advised hospitals to make sure vincristine syringes are properly labeled with warnings that spinal injections are fatal, and that the drug is for intravenous use only.

Vincristine also should be given to patients at different times and in different rooms than drugs administered through the spine, the alert said.

"We need to be vigilant about this," Seger said. "I'm glad JCAHO has done down this path."