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NCCN Challenges Medical Community to ‘Just Bag It’ to Eradicate Deadly Medical Error

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As part of its mission to improve the quality, effectiveness, and efficiency of cancer care so that patients can live better lives, the National Comprehensive Cancer Network® (NCCN®) has announced the launch of Just Bag It: The NCCN Campaign for Safe Vincristine Handling. This campaign encourages health-care providers to adopt a policy to always dilute and administer vincristine in a mini–intravenous (IV) drip bag to prevent a particular deadly medical error.

When vincristine enters the blood, it is highly effective at blocking the growth of cancer by preventing cells from separating.  However, the drug is a neurotoxin that causes peripheral neuropathy when given intravenously and profound neurotoxicity if administered via the spinal fluid. Many patients who receive vincristine have a treatment regimen that includes other chemotherapy drugs administered intrathecally. If vincristine is mistakenly administered into the spinal fluid, it is uniformly fatal, causing ascending paralysis, neurologic defects, and eventually, death.

Motivating Incident

In 2005, NCCN Chief Executive Officer Robert W. Carlson, MD, a medical oncologist, witnessed such a tragedy with a 21-year-old patient with non-Hodgkin lymphoma named Christopher Wibeto. Mr. Wibeto was transferred to Dr. Carlson’s care after receiving incorrectly administered vincristine at another hospital. Dr. Carlson watched the young man go from having a likely curable condition to deteriorating and dying within 4 days. Motivated by this tragic experience, Dr. Carlson spearheaded a national effort to address this deadly error when he arrived at NCCN, enlisting the help of its Best Practices Committee, which is dedicated to improving cancer treatment protocols.

To ensure that vincristine is always administered properly, NCCN has issued guidelines advising health-care providers to always dilute and administer vincristine in a mini–IV drip bag and 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.

All 27 NCCN Member Institutions have adopted policies in line with these guidelines, which are also recommended by the Institute for Safe Medication Practices, the Joint Commission, the World Health Organization, and the Oncology Nursing Society.

“We are proud of this achievement and grateful for the support and participation of our Member Institutions in reaching this goal,” Dr. Carlson said. “Our efforts will not stop here. We challenge all medical centers, hospitals, and oncology practices around the nation and the world to implement this medication safety policy so this error never occurs again.”

Increasing Trend

Surveys issued by the Institute for Safe Medication Practices (ISMP) show that over time, more hospitals have adopted a policy to always bag vincristine. According to ISMP data, the number of hospitals that have fully implemented the policy across their practice nearly doubled between February 2014 and February 2016. Earlier surveys indicated a similar increase between 2005 and 2012. Still, only about half of all respondents indicated that they have implemented the policy in all treatment settings, indicating that there is a long way to go.

With 125 known cases of accidental death in the U.S. and abroad since the inception of vincristine use in the 1960s, this error is relatively rare. Still, it is unique in its level of mortality. Improvements in practice over the years, including manufacturer- and pharmacist-issued warning labels, have reduced the number of deaths, but the error continues to occur.

Diluting vincristine into a mini–IV drip bag may entail a change in practice for some providers, but it is well worth the outcome of avoiding preventable deaths, according to Michael Cohen, RPh, MS, FASHP, President of ISMP.

“One more life taken is one too many,” Dr. Cohen said. “We are glad an organization of NCCN’s influence has stepped up to bring this issue to national attention. Ending this devastating error should be a priority for all of us who care for and advocate on behalf of patients and their families.”

Extravasation Concerns

Some health-care providers may associate the use of an IV bag with a heightened risk of extravasation. But research has shown that the risk of a chemotherapy drug leaking into the tissue surrounding the IV administration site is extremely low (< 0.05%), regardless of how vincristine is administered.

“The Just Bag It campaign is the latest of NCCN’s long-standing efforts to improve the safe use of drugs in cancer care,” said F. Marc Stewart, MD, Medical Director of the Seattle Cancer Care Alliance, Member of the Fred Hutchinson Cancer Research Center, Professor of Medicine at University of Washington, and Co-Chair of the NCCN Best Practices Committee. “For more than 15 years, the Best Practices Committee has worked to ensure the highest standards of safety for patients.”

For more information about Just Bag It: The NCCN Campaign for Safe Vincristine Handling, or to report that a medical facility has adopted a vincristine policy, visit www.NCCN.org/JustBagIt.

The content in this post has not been reviewed by the American Society of Clinical Oncology, Inc. (ASCO®) and does not necessarily reflect the ideas and opinions of ASCO®.


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