Acute Care Volume 24, Issue 5

Medication Safety Alert! March 14, 2019

In this week's issue:

Featured article

Since January 2019, ISMP has learned about 4 children who received vinCRIStine erroneously by the intrathecal route of administration, each suffering a very painful death. Three of the children were from Guyana, and one was from Norway. The child from Norway had a brain tumor and was just 6 years old when vinCRIStine was injected into the spinal fluid via an intraventricular catheter instead of methotrexate. The three children from Guyana were just 3, 6, and 7 years old.

The most effective way to prevent patient harm is to supply all vinca alkaloids in minibags, thus avoiding the risk of...

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