Doctors suspended after injecting wrong drug into spine
BMJ 2001; 322 doi: https://doi.org/10.1136/bmj.322.7281.257 (Published 03 February 2001) Cite this as: BMJ 2001;322:257
Two doctors at Queen's Medical Centre in Nottingham have been suspended and could face manslaughter charges over an injection mix-up that has left a patient close to death.
A teenager with leukaemia has had the anticancer drug vincristine injected into his spine instead of via the correct route—into a vein.
The same mistake has caused 10 previous deaths in Britain. The blunder happens because vincristine is given in conjunction with an intrathecal drug and doctors mix up the two, although the packaging for vincristine warns that the drug is fatal if injected into the spine. The patient's only chance of survival is if the error is realised quickly and a “wash out” is performed. Of 13 previous cases in Britain since 1985, 10 have been fatal and the rest have resulted in paralysis.
Professor Gordon McVie, director general of the Cancer Research Campaign, said: “It is unspeakable that this should happen in this day and age. It is truly horrible. This drug should never be given by anyone other than a consultant.”
The 19 year old patient, whose parents have asked for his name to be withheld, was told what had happened before he slipped into unconciousness a week after the injection was given on 4 January.
In 1991 two junior doctors at Peterborough general hospital were convicted of manslaughter for injecting vincristine into the spine of a 15 year old patient. Their conviction was later overturned on appeal.
In 1999 two doctors at Great Ormond Street hospital in London were formally cleared of manslaughter at the Old Bailey after the Crown Prosecution Service dropped charges against them. Prosecutors decided the death of 12 year old Richie William was caused by a catalogue of “chance events and failings” at the hospital rather than gross negligence by the doctors.
A spokesman for the Department of Health said that a new mandatory system was being set up for reporting adverse events and “near misses,” so that lessons could be learned throughout the NHS. “The specific work on spinal injections is being led by Professor Kent Woods, director of the NHS technology assessment programme,” he added.
A full inquiry has been started at Queen's Medical Centre to discover what went wrong. (See p 247.)
Pharmacy staff are instructed to dilute vincristine to at least 10 ml. The larger size syringe is meant to alert doctors to the fact that it should not be injected intrathecally (see box)
Safeguards used to stop certain drugs being given intrathecally
Cytotoxic drugs should be given only by specialist, appropriately trained staff
The dose of vinca alkaloid should be diluted to at least 10 ml to help distinguish it from drugs intended for intrathecal injection, for which such a large volume is rarely given
All administration devices containing vinca alkaloids must be labelled: “Warning: Vin…(drug name): For intravenous use only”
Intrathecal drugs should be administered in a designated area—for example, an operating theatre
Drugs for intrathecal use should be delivered to the point of use from the pharmacy at a different time and packed separately from other drugs
No other cytotoxic drugs should be delivered to or stored in such a designated area.