External Inquiry into the adverse incident that occurred at Queen’s Medical Centre, Nottingham, 4th January 2001 (17 April 2001)

Summary

This report describes an adverse incident at Queen's Medical Centre in Nottingham in 2001, when a male patient being treated for leukaemia died after being mistakenly given the chemotherapy drug Vincristine intrathecally (into the spine). Vincristine should be administered intravenously, and accidental intrathecal administration of Vincristine is almost always fatal.

Content

The report provides information on the patient involved and background to the adverse incident, analyses the reasons for the incident and provides recommendations  for the administration of intrathecal chemotherapy to prevent a similar incident occurring in the future:

Recommendations include:

• changes to operational practices in pharmacy and ward settings
• changes to protocols in pharmacy and ward settings
• the provision of separate prescri0ption charts for intrathecal drugs
• formal, appropriate training on practical chemotherapy administration for senior house officers and specialist registrars
• enhanced checking procedures, involving the patient and family as well as medical staff
• agreed limits on the involvement of staff under supervision or shadowing
• a targeted communications campaign about the dangers of incorrect administration of Vincristine
• distinctive and clear labelling for intrathecal drugs
• the development of a new spinal needle with a different connection, to avoid accidental introduction of intravenous drugs.

Related reading

Safe administration of intrathecal chemotherapy (2003)