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Publication Type: Alert
Single or Multiple Incident: Multiple
Date: 1/1/2017 12:00:00 AM
This alert describes three cases of medication errors involving intrathecal methotrexate and cytarabine. In the first case, two patients were to receive intrathecal methotrexate with fluoroscopic guidance, Patient A in the morning and Patient B in the afternoon. The pharmacist dispensed the two methotrexate doses and the syringe for Patient A was delivered to his ward that morning. However, the syringe was not delivered before Patient A was transported to radiology. When Patient A arrived in the radiology suite, the technician called over to pharmacy looking for Patient A’s medication. In the pharmacy, the tech saw a single syringe labeled for intrathecal use and delivered it to radiology. This error was discovered when the pharmacist made afternoon deliveries and saw that Patient A’s syringe was still on the ward even though Patient A had already returned from the procedure. Patient A had received Patient B’s medication. In the second case, cytarabine was to be administered subcutaneously but given intrathecally. Lastly methotrexate was sent for administration in error; intrathecal cytarabine was to be given. The error was caught before administration. The alert provides several contributing factors relating to incidents with intrathecal chemotherapy and provides recommendations for reducing the likelihood of events.

Additional Details

Medication/Gas/Fluid:
NRFit connector, intravenous syringe
Medication/IV List:
chemotherapeutic agents, parenteral and oral

Environment / Equipment
  1. The NRFit connector, designed so that intravenous syringes are not interconnectable with intrathecal or other neuraxial devices, will provide an additional layer of protection.
Rules / Policies / Procedures
  1. Make bar code scanning occur reliably during intrathecal procedures. However, while bar code medication administration does help with wrong patient or wrong time errors, it is not a strong protection for wrong-route errors. A correct scan is not assurance that the drug should be given intrathecally.

Echoes of Past Disasters