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Essentials

Vincristine Minibag Administration: A Quality Improvement Project to Minimize Medical Errors

Clara Beaver
CJON 2018, 22(6), 669-672 DOI: 10.1188/18.CJON.669-672

Vincristine is a cytotoxic chemotherapy agent classified as an antitumor alkaloid and is part of the vinca alkaloid family. Vincristine’s mechanism of action is to primarily inhibit mitosis of the cancer cell and is given by IV route only for treatment. Accidental intrathecal administration of vincristine has lethal consequences for patients. To minimize the risk of accidental intrathecal administration of vincristine, 14 infusion centers participated in a quality improvement project to change the practice of vincristine administration from IV push to IV piggyback via minibag and gravity. After three months, all infusion centers successfully implemented the practice.

AT A GLANCE

  • Vincristine administration using minibag with IV piggyback via gravity increases patient safety and prevents adverse events.
  • A vincristine minibag policy was developed using a quality improvement method to standardize administration.
  • A scripted video and checklist, including a demonstration of competencies for nurse training, eliminate the risk of unconscious trainer bias.

Vincristine is a vinca alkaloid that has been used in practice for more than 50 years. Since its introduction as a chemotherapy agent, it has been used to treat hematologic cancers, such as leukemia and lymphoma, and childhood sarcomas. Vincristine is administered to patients via IV. Accidental intrathecal administration of vincristine can be lethal for patients, causing ascending paralysis, neurologic defects, and eventual death (Corbitt et al., 2017; National Comprehensive Cancer Network [NCCN], 2016). Care must be taken when administering the drug to avoid patient harm (Corbitt et al., 2017). Since the 1960s, 125 deaths have been attributed to improper administration of vincristine (Institute for Safe Medication Practices, 2013). The risk of making this error is greatest when chemotherapy regimens include vincristine in addition to intrathecal chemotherapy agents (Corbitt et al., 2017).

Vincristine is considered a vesicant chemotherapy agent, which requires close observation of the site during IV administration. The Oncology Nursing Society (Polovich, Olsen, & LeFebvre, 2014) recommends that, when administering vesicant therapy, nurses avoid using an IV pump or syringe pump, remain with the patient throughout the infusion, verify blood return every 5–10 minutes for short infusions, and monitor for signs and symptoms of extravasation during infusion.

In 2016, the NCCN launched the Just Bag It campaign to showcase the importance of patient safety and the safe handling of vincristine. The American Society of Clinical Oncology and Oncology Nursing Society also recommend the standardization of minibag administration for all vinca alkaloids (Neuss et al., 2016). Many organizations (e.g., Joint Commission, Oncology Nursing Society) support initiatives to eliminate vincristine administration errors by using minibags for IV administration (Joint Commission, 2017). The Joint Commission (2017) urges that IV vincristine never be dispensed at a location where intrathecal chemotherapy is administered, as well as reinforces the National Patient Safety Goal of adherence to medication safety processes, including medication double checks and labeling.

In some cancer centers, vincristine is given IV push using a large-volume syringe. Accidental intrathecal administration of vincristine can occur if the syringe containing vincristine for IV administration is mixed up with a syringe containing a drug for intrathecal administration (Institute for Safe Medication Practices, 2017).

Policy and practice changes can minimize the risk of accidental intrathecal administration (Neuss et al., 2016). As a result, a quality improvement initiative was implemented at the author’s healthcare system to change the method of vincristine IV administration using a syringe to using a minibag. The purpose of the initiative was to (a) introduce a new standard of care related to the preparation and administration of vincristine and (b) validate the uptake and standardization of this new standard of care across 14 infusion centers in the author’s healthcare system.

Minibag Administration

In collaboration with the pharmacy, the infusion centers stopped preparing vincristine syringes for IV administration. Under the new guidelines, vincristine for IV infusion had to be mixed in a minibag, with a label reading, “Administer via gravity.” When administering vincristine using a minibag, nurses have less control over the vesicant administration and may be tempted to place the minibag on a pump for ease of infusion, such as when the patient has a central line. Reminding nurses about the vesicant nature of the medication is important in preferred use of gravity when administering vincristine via minibag.

To ensure consistency in the teaching of the new vincristine policy and practice, the education and training program were standardized with a scripted education video of vincristine administration and a nurse skills checklist. This standardization was particularly important because the new guideline and administration practice needed to be implemented in 14 infusion centers across the system. The scripted video and guidelines minimized the risk of misrepresentation and misinterpretation. Nurses in each of the 14 infusion centers had one month to watch the education video and complete a clinical validation skills checklist (see Figure 1) under the direct observation of a trained validator.

Evaluation

During a three-month period, validation of all infusion nurses who had adopted the new practice was conducted. To ensure sustained adherence to the guidelines, trainers continued to evaluate infusion nurse practices at least once a year through direct observation. This method of peer evaluation helped detect and correct any deviation from the standard of practice. During the evaluation period, trainers observed some nurses administering vincristine via IV pump when patients had a central line. To ensure consistent practice across all sites, the training video was updated, demonstrating vincristine administration via IV piggyback and gravity through a peripheral line and a central line.

Conclusion

Patient safety is a priority for all healthcare providers. Nurses play a special role in promoting patient safety and minimizing the risk of errors by questioning practice and developing safer procedures.

Practice change can be difficult. However, the author’s experience suggests that education with clinical validation of the uptake of new knowledge can facilitate the adoption of a new practice. Using a scripted video and checklist ensured that the same content was delivered to all participants.

About the Author(s)

Clara Beaver, MSN, RN, AOCNS®, ACNS, BC, is a clinical nurse specialist at the Barbara Ann Karmanos Cancer Institute in Detroit, MI. The author takes full responsibility for this content and did not receive honoraria or disclose any relevant financial relationships. Beaver can be reached at beaverc@karmanos.org, with copy to CJONEditor@ons.org.

 

References 

Corbitt, N., Malick, L., Nishioka, J., Rigdon, A., Szoch, S., & Torr, P. (2017). Instituting vincristine minibag administration: An innovative strategy using simulation to enhance chemotherapy safety. Journal of Infusion Nursing, 40, 346–352.

Institute for Safe Medication Practices. (2013). Death and neurological devastation from intrathecal vinca alkaloids: Prepared in syringes = 120; prepared in minibags = 0. Retrieved from https://www.ismp.org/resources/death-and-neurological-devastation-intrat...

Institute for Safe Medication Practices. (2017). Targeted medication safety best practices for hospitals. Retrieved from https://www.ismp.org/guidelines/best-practices-hospitals

Joint Commission. (2017). Eliminating vincristine administration events. Retrieved from https://www.jointcommission.org/assets/1/23/Quick_Safety_Issue_37_2017_V...

National Comprehensive Cancer Network. (2016). Just bag it! NCCN campaign for safe vincristine handling. Retrieved from https://www.nccn.org/justbagit

Neuss, M.N., Gilmore, T.R., Belderson, K.M., Billett, A.L., Conti-Kalchik, T., Harvey, B.E., . . . Polovich, M. (2016). 2016 updated American Society of Clinical Oncology/Oncology Nursing Society chemotherapy administration safety standards, including standards for pediatric oncology. Journal of Oncology Practice, 12, 1262–1271.

Polovich, M., Olsen, M., & LeFebvre, K. (Eds.). (2014). Administration considerations. In Chemotherapy and biotherapy guidelines and recommendations for practice (4th ed., p. 129). Pittsburgh, PA: Oncology Nursing Society.