In Oncology Nursing, One Small Change Can Potentially Prevent Deadly Medical Error in Thousands of Patients

This week at the ONS 42nd Annual Congress, experts from The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins present results of a patient safety initiative to administer vincristine via IV mini-bag, rather than syringe, echoing NCCN’s Just Bag It Campaign.

Article ID: 673864

Released: 1-May-2017 2:00 PM EDT

Source Newsroom: National Comprehensive Cancer Network® (NCCN®)

  • Vincristine prepared in mini-IV drip bag

Newswise — [FORT WASHINGTON, PA — May 1, 2017] Vinca alkaloids such as vincristine, are important chemotherapeutic agents that are highly effective at blocking the growth of cancer. Many patients who receive vincristine have a treatment regimen that includes other chemotherapy drugs that are administered intrathecally, or injected into the spinal fluid with a syringe. If vincristine is mistakenly administered into the spinal fluid, it is uniformly fatal, causing ascending paralysis, neurological defects, and eventually death. This mistake, however, is almost completely avoidable with one small administration change—instead of “pushing” intravenous (IV) vinca alkaloids via syringe, experts now call for these agents to be diluted into mini-IV drip bags.

This week, during the Oncology Nursing Society (ONS) 42nd Annual Congress, MiKaela Olsen, MS, APRN-CNS, AOCNS, The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, will present results of a center-wide effort to administer vincristine via mini-IV drip bags in a poster titled, Putting an Old Oncology Nursing Practice to Bed: A Hospital-Wide Initiative Using Evidence-Based Practice to Standardize the Administration of Vinca Alkaloids Using a Minibag, Side-Arm Technique.

This presentation comes on the heels of the National Comprehensive Cancer Network® (NCCN®)’s 2016 Just Bag It! Campaign for the safe administration of vincristine.

According to Ms. Olsen and her colleagues, there are a number of barriers to standardizing vincristine administration in mini-IV drip bags. For instance, they note that nurses may believe the risk of extravasation to be higher than when pushing the agent. However, when analyzing 12 months of data at Johns Hopkins Hospital, Olsen, et al, found zero cases of extravasation among the more than 1,300 mini-bag administrations of vincristine after the practice change.

“This was a big change in practice for bedside nurses at Johns Hopkins Hospital who had, to this point, always administered vesicants—other than continuous infusion vesicants—as an intravenous push through the side port of a free-flowing line. Using an evidence-based practice approach to tackle this clinical practice issue was key to our success,” said Ms. Olsen. “Just because it was always done a certain way does not mean it is the safest way.”

According to Ms. Olsen, the program facilitators provided background education to provider, pharmacy, and nursing staff that included a review of cases of patient harm with recommended guidelines for prevention and used the same technique that nurses were used to; however, instead of pushing the medication through a syringe, the nurse holds the mini-bag as it runs through the side port of a free flowing line.

“Nurses performed the procedure in a skills lab environment to ensure understanding of proper technique for safe mini-bag administration to prevent extravasation. This approach was key to our success,” said Ms. Olsen.  

Other barriers noted by the researchers include a lack of understanding of the risk of death associated with central nervous system administration of vincristine, as well as a lack of understanding of how to properly administer vinca alkaloids via drip bag.

To thwart these concerns at the time of the administration switch over, a short video was produced for the nursing staff, demonstrating the proper side-arm drip administration of vincristine, and all RN staff attended a hands-on skill lab. RN staff are instructed to remain with the patient during the entire five-minute administration, checking blood returns every two minutes and at the completion of the infusion. Additionally, labeling of vincristine must be clear and stated as such: “For intravenous use only – fatal if given other routes.”

“At Johns Hopkins Hospital, our pediatric colleagues made this successful practice change first.  After thoughtful design of the step-by-step procedure, policy revisions, and collaboration between nursing and pharmacy, the change was implemented in adult oncology,” said Ms. Olsen. “Our staff feel confident that this new procedure is safe and that it is absolutely the right thing to do to prevent patient harm. Once we made the change, we did not look back.  Eliminating the risk of harm was our number one priority.”

Ms. Olsen will present her findings from 5:30 – 6:30 PM on Friday, May 5, 2017.

“The oncology nursing community plays an imperative role in the day-to-day, hands-on care and protection of patients with cancer. NCCN applauds Johns Hopkins, as well as the staff and faculty of our other Member Institutions, for their dedication to patient safety,” said Robert W. Carlson, MD, Chief Executive Officer, NCCN. “We are pleased that Ms. Olsen has the opportunity to share her findings with the esteemed ONS audience and hope her work is the impetus for others to change their practices.”

In 2005, Dr. Carlson, a medical oncologist, witnessed sequelae of such a tragedy with a 21-year-old patient with Non-Hodgkin’s Lymphoma named Christopher Wibeto. Wibeto was transferred to Dr. Carlson’s care after receiving incorrectly administered vincristine at another hospital. Dr. Carlson watched the young man go from having a likely curable condition to deteriorating and dying within four days. Motivated by this tragic experience, Dr. Carlson spearheaded a national effort to address this deadly error when he arrived at NCCN, enlisting the help of its Best Practices Committee, which is dedicated to improving cancer treatment protocols.

To ensure that vincristine is always administered properly, NCCN has issued guidelines advising health care providers to always dilute and administer vincristine in a mini-IV drip bag and never use a syringe to administer the medication. This precaution renders it impossible to accidentally administer the medication into the spinal fluid and greatly decreases the chances of improper dosage.

All 27 NCCN Member Institutions, including The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, have adopted policies in line with these guidelines, which are also recommended by the Institute for Safe Medication Practices, the Joint Commission, the World Health Organization, and the ONS.

In March 2017, NCCN issued a challenge to raise the number of reported adopters of these policies to 100 centers or practices. To report adoption of these practices, visit NCCN.org/JustBagIt.

In 2008, the NCCN Best Practices Committee led the charge for NCCN to begin publishing Chemotherapy Order Templates (NCCN Templates®), which detail the most common regimens for many cancers and highlight safety parameters. These resources enable practitioners to standardize patient care, reduce medication errors, and anticipate and manage adverse events. There are more than 1,500 NCCN Templates® for 86 cancer types, and they are used by more than 10,000 subscribers.

For more information about Just Bag It: The NCCN Campaign for Safe Vincristine Handling, or to report that a medical facility has adopted a vincristine policy, visit NCCN.org/JustBagIt or visit NCCN’s Booth (#118) at the ONS Annual Congress.

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About the National Comprehensive Cancer Network

The National Comprehensive Cancer Network® (NCCN®), a not-for-profit alliance of 27 leading cancer centers devoted to patient care, research, and education, is dedicated to improving the quality, effectiveness, and efficiency of cancer care so that patients can live better lives. Through the leadership and expertise of clinical professionals at NCCN Member Institutions, NCCN develops resources that present valuable information to the numerous stakeholders in the health care delivery system. As the arbiter of high-quality cancer care, NCCN promotes the importance of continuous quality improvement and recognizes the significance of creating clinical practice guidelines appropriate for use by patients, clinicians, and other health care decision-makers.

 

The NCCN Member Institutions are: Fred & Pamela Buffett Cancer Center, Omaha, NE; Case Comprehensive Cancer Center/University Hospitals Seidman Cancer Center and Cleveland Clinic Taussig Cancer Institute, Cleveland, OH; City of Hope Comprehensive Cancer Center, Los Angeles, CA; Dana-Farber/Brigham and Women’s Cancer Center | Massachusetts General Hospital Cancer Center, Boston, MA; Duke Cancer Institute, Durham, NC; Fox Chase Cancer Center, Philadelphia, PA; Huntsman Cancer Institute at the University of Utah, Salt Lake City, UT; Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance, Seattle, WA; The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD; Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, IL; Mayo Clinic Cancer Center, Phoenix/Scottsdale, AZ, Jacksonville, FL, and Rochester, MN; Memorial Sloan Kettering Cancer Center, New York, NY; Moffitt Cancer Center, Tampa, FL; The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute, Columbus, OH; Roswell Park Cancer Institute, Buffalo, NY; Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine, St. Louis, MO; St. Jude Children’s Research Hospital/The University of Tennessee Health Science Center, Memphis, TN; Stanford Cancer Institute, Stanford, CA; University of Alabama at Birmingham Comprehensive Cancer Center, Birmingham, AL; UC San Diego Moores Cancer Center, La Jolla, CA; UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, CA; University of Colorado Cancer Center, Aurora, CO; University of Michigan Comprehensive Cancer Center, Ann Arbor, MI; The University of Texas MD Anderson Cancer Center, Houston, TX; University of Wisconsin Carbone Cancer Center, Madison, WI; Vanderbilt-Ingram Cancer Center, Nashville, TN; and Yale Cancer Center/Smilow Cancer Hospital, New Haven, CT.

 Clinicians, visit NCCN.org. Patients and caregivers, visit NCCN.org/patients. Media, visit NCCN.org/news.


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