Congress Abstracts 2006

22

PREVENTING INTRATHECAL ADMINISTRATION OF VINCRISTINE: AN INSTITUTIONAL RESPONSE TO THE SENTINEL EVENT ALERT ISSUED BY THE JOINT COMMISSION ON ACCREDITATION OF HEALTHCARE ORGANIZATIONS. Maria Slezak, RN, BSN, OCN^®, University of California, San Diego (UCSD), Medical Center-Moores UCSD Cancer Center, San Diego, CA; Marlon Saria, MSN, RN, AOCN^®, UCSD Medical Center, San Diego, CA; and Susan Wilson, PharmD, UCSD Medical Center-Moores UCSD Cancer Center, San Diego, CA.

Topic: This quality improvement project describes the response of a university-affiliated healthcare system operating two medical centers and a newly-opened National Cancer Institute (NCI) designated Cancer Center to the sentinel event alert issued by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) on prevention of intrathecal administration of vincristine.

Problem/Purpose: Inadvertent intrathecal administration of vincristine is a fatal yet very preventable error. Despite specific requirements for labeling and a rigid dispensing standard imposed by the United States Pharmacopeia (USP), these errors continue to occur. The goal of this quality improvement project is to prevent such error from occurring at our institution

Interventions: The medical center policy "Antineoplastic drugs: Staff education, cytotoxic drug handling precautions and administration" was revised to include JCAHO recommendations on the administration of intravenous vincristine and intrathecal antineoplastic medications. Vincristine will no longer be dispensed in a 3mL syringe to preclude intrathecal administration and will only be delivered to the unit upon receiving a confirmation from nursing that intrathecal administration of another antineoplastic drug is not imminent or has been completed. In order to address the often omitted documentation of intrathecal medication verification, we have also developed a multidisciplinary check off sheet that will accompany the intrathecal medication from Pharmacy, to the nursing unit, and eventually to the patient's bedside.

Interpretation / Evaluation: Mandate from the Patient Safety Committee to address the sentinel event alert on preventing inadvertent intrathecal administration of vincristine issued by a regulatory agency (JCAHO) and findings from mock surveys conducted on the various oncology units outlined the need for a better documentation of intrathecal drug administration. The proposed changes have been approved by the various committees at our institution and have preserved our zero error rate for inadvertent intrathecal administration of vincristine.