Background
The Safety and Quality Council has developed a national alert system for high risk medications. The aim of this national communication strategy is:- to warn health leaders and professionals about serious known medication hazards
- to provide tools to effectively ensure action to reduce the hazards
- to set out responsibilities for system change.
The Safety and Quality Council gratefully acknowledges the contribution of many groups who have worked together to contribute to the content of this alert, as well as its wide dissemination to all public and private hospitals and health care professionals. This partnership approach is recognized as being fundamental to achieving improvements in the safety of our health system. Long term actions will be required to implement systems to overcome known medication hazards, and to regularly review and evaluate those systems.
Vincristine injection is the subject for the second alert. Vincristine, a medicine commonly used in the treatment of leukaemias and lymphomas, is neurotoxic and must only be administered intravenously. Sentinel events associated with the inadvertent intrathecal administration of vincristine have been repeatedly reported in Australia and overseas. Adults and children are at risk with 50% of reported cases in each group. This error results in a fatal outcome in 85% of cases with devastating neurological effects in the few survivors.
Many hospitals have already implemented risk management strategies for intravenous vincristine. This alert draws on international and Australian work to make a range of recommendations. All facilities should evaluate their safety controls against the alert recommendations.
Medication alert
Read on... Medication Alert 2 - VINCRISTINE, December 2005 (PDF 67 KB)This alert includes the following references:
- Reference 5 - ISMP Medication Safety Alert, December 2005
- Reference 6 - UK National guidance on the safe administration of intrathecal chemotherapy
- Reference 7 - JCAHO Sentinel Event Alert, July 2005
- Reference 8 - ISMP Canada Safety Bulletin, October 2001
- Reference 13 - Literature review (PDF 139 KB)
Change Management Case Studies - Vincristine
Several facilities have commenced implementation of actions recommended in the Alert. Two major teaching hospitals have kindly agreed to share with others their learning experiences and how they went about changing their systems. These change management case studies address:- Why vincristine was selected?
- Who "drove" the initiative and who was involved?
- What communication was undertaken?
- What barriers were encountered and how were they overcome?
- What were the short term "wins"?
- What still needs to be done?
Similar change management case studies are invited from others. In particular, sharing of information from different settings eg. private hospitals, rural hospitals, day care facilities would greatly assist progress in those settings.
There are also examples from Mater Health Services of
- Policy: Administration of Intrathecal Chemotherapy (PDF 31 KB)
- Intrathecal Chemotherapy Administration Competency Assessment (PDF 49 KB)
There is also an example from Royal Adelaide Hospital of:
Background documents
Literature review (PDF 139 KB)- The literature review that was undertaken for the vincristine high risk alert project (to December 2005) is available for background information.
Cases reported summary (PDF 35 KB)
- A summary of the case reports of misadventure with vincristine (to December 2005) is available for background information.
Acknowledgement of stakeholder involvement
The following organisations and government agencies are acknowledged for their input and/or dissemination of this alert notice:ADGP - Australian Divisions of General Practice
ADRAC - Adverse Drug Reactions Advisory Committee
ADSA - Australasian Day Surgery Association
AIMS - Australian Incident Monitoring System
ANZCHOG - Australian and New Zealand Children's Haematology Oncology Group
ANF - Australian Nursing Federation
APAC - Australian Pharmaceutical Advisory Council
APHA - Australian Private Hospitals Association
Australian DoHA - Australian Department of Health and Ageing
Australian Government PHIB - Private Health Insurance Branch
Baxter Healthcare Pty. Limited
CHF - Consumers' Health Forum
COSA - Clinical Oncological Society of Australia
CNSA - Cancer Nurses Society of Australia
MOGA - Medical Oncology Group of Australia
MUNCCI - Monash University National Centre for Coronial Information
NCIS - National Coroner's Information Service
NICS - National Institute for Clinical Studies
NPS - National Prescribing Service
NSWTAG - NSW Therapeutic Assessment Group Inc
NTD&TC - Northern Territory Drug and Therapeutics Committee
PFK - Pharmatel Fresenius Kabi
QHDAC - Queensland Hospitals Drug Advisory Committee
RACMA - Royal Australian College of Medical Administrators
RACP - The Royal Australian College of Physicians
RACS - Royal Australian College of Surgeons
SATAG - South Australian Therapeutic Advisory Group
SHPA - Society of Hospital Pharmacists of Australia
SQOF - State Quality Officials Forum
TSTDC - Tasmanian Statewide Therapeutic Drug Committee
VicTAG - Victorian Therapeutics Advisory Group
VMAC - Victorian Medicines Advisory Committee
WATAG - Western Australian Therapeutics Advisory Group
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