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Journal of Clinical Oncology, Vol 22, No 5 (March 1), 2004: pp. 965 © 2004 American Society of Clinical Oncology. DOI: 10.1200/JCO.2004.99.127
The Vincotube System: A Design Solution to Prevent the Accidental Administration of Intrathecal Vinca AlkaloidsDepartment of Medical Oncology, Charing Cross Hospital, London, United Kingdom To the Editor: The development of an effective preventive strategy is the key to avoiding future incidents of accidental intrathecal administration of vinca alkaloids. The safety procedure described by Worner et al [1] has been in place in the United Kingdom as a national guideline since 2001 [2] and the procedure advocated by Stefanou and Dooley [3] also has been put forward previously [4]. To improve further patient safety, we propose a novel packaging system for intravenous (IV) vincristine, named the Vincotube System, which should reduce the risk of inadvertent intrathecal administration. Intrinsic to the design is a series of interlinked safety devices, each of which would need to be broken for a dangerous error to occur. The system is illustrated in Figure 1. A key part of this system is a specially designed syringe that would be readily distinguishable from all other currently available syringes by the addition of a red plunger and the warning "For IV use only" printed in red. The syringe is the last line of protection should all other parts of the system fail, and the red plunger must become synonymous with IV use. The syringe would be sealed in a red bag labeled with a large, clear warning.
The outer packaging is a red cylinder that is both functional and instantly recognizable. Clearly printed on its surface is the warning "For IV use only." It can be stored upright or on its side and has a small footprint, enabling easy storage and handling. The outer tube is sealed by a red tag, which protects against tampering and serves as an alert to whoever breaks the seal. The packaging system should be supported by an educational video or CD-ROM containing current guidelines for the administration of intrathecal drugs as well as an explanation of the Vincotube System. The Vincotube System is a positive and innovative step toward managing the inherent risks associated with parenteral administration of vinca alkaloids and represents a design solution as called for in a recent publication by the Medicines Control Agency in the United Kingdom [5]. This system does not aim to replace current guidelines published in the United Kingdom [4] or elsewhere [1], but rather aims to be integrated into these existing guidelines to further enhance patient safety. Authors' Disclosures of Potential Conflicts of Interest The authors indicated no potential conflicts of interest.
REFERENCES
1. Worner RB, Tracey E, Soo-Hoo W, et al: Multidisciplinary systems approach to chemotherapy safety: Rebuilding processes and holding the gains. J Clin Oncol 20:4705–4712, 2002 2. National guidelines on the safe administration of intrathecal chemotherapy. London, UK, Department of Health, 2001
3. Stefanou A, Dooley M: Simple method to eliminate the risk of inadvertent intrathecal vincristine administration. J Clin Oncol 21:2044, 2003 4. Woods K: The prevention of intrathecal medication errors, a report to the Chief Medical Officer. London, UK, Department of Health, 2001 5. Report to the committee on safety of medicines from the working group on labelling and packaging of medicines. London, UK, Medicines Control Agency, 2001
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Copyright © 2004 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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