Newswise — [FORT WASHINGTON, PA — August 7, 2017] During the launch of the campaign in November 2016, the National Comprehensive Cancer Network® (NCCN®) called on cancer centers and practices that deliver chemotherapy to commit to Just Bag It: The NCCN Campaign for Safe Vincristine Handling. Today, NCCN announces that 100 adopters have confirmed their participation in the effort. The full list is available at NCCN.org/justbagit.
As part of its mission to improve the quality, effectiveness, and efficiency of cancer care so that patients can live better lives, NCCN launched the Just Bag It! campaign to encourage health care providers across the United States and the world to adopt a policy to always dilute and administer vincristine in a mini IV-drip bag to prevent a deadly medical error.
“NCCN commends the efforts of the 100 cancer centers, including the 27 NCCN Member Institutions, who have demonstrated their commitment to patient safety, and we thank them for pushing our message forward,” said Robert W. Carlson, MD, Chief Executive Officer, NCCN. “NCCN hopes the number of pledges will continue to climb as centers become more aware of this small change that indeed saves patients’ lives.”
Prior to the launch in November, all 27 NCCN Member Institutions had adopted policies in line with the Guidelines, which are also recommended by the Institute for Safe Medication Practices, the Joint Commission, the World Health Organization and the Oncology Nursing Society. Since the press conference that gained local and national attention, NCCN has continued its campaign through e-mail and social media outreach, as well as live meetings, including the NCCN Patient Advocacy Summit, the NCCN 22nd Annual Conference, and the Oncology Nursing Society Annual Congress.
Vincristine is a chemotherapy agent, widely used in patients with Leukemia or Lymphoma, which should be administered intravenously—directly into the patient’s vein. When it enters the blood, it is highly effective at blocking the growth of cancer by preventing cells from separating. However, vincristine is a neurotoxin that causes peripheral neuropathy when given intravenously and profound neurotoxicity if given into the spinal fluid, which flows around the spinal cord and brain.
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 administered mistakenly into the spinal fluid, it is uniformly fatal, causing ascending paralysis and eventual death.
In 2005, NCCN Chief Executive Officer Robert W. Carlson, MD, a medical oncologist, witnessed 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 treatable condition to deteriorating and dying over the course of 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.
“The Just Bag It campaign is the latest of NCCN’s long-standing efforts to improve the safe use of drugs in cancer care,” said F. Marc Stewart, MD, Medical Director of the Seattle Cancer Care Alliance, Member of the Fred Hutchinson Cancer Research Center, Professor of Medicine at University of Washington, and Co-Chair of the NCCN Best Practices Committee. “For more than 15 years, the Best Practices Committee has worked to ensure the highest standards of safety for patients, and we applaud the 100 adopters of this policy at their treatment centers.”
To ensure that vincristine is always administered properly, NCCN has issued guidelines and updated NCCN Chemotherapy Order Templates (NCCN Templates®) 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.
MiKaela Olsen, MS, APRN-CNS, AOCNS, an oncology nurse at The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, one of the NCCN Member Institutions, recently spearheaded a center-wide effort to administer vincristine via mini IV-drip bags, the results of which she presented at the Oncology Nursing Society Annual Congress in May.
“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.”
With 125 known cases of accidental death in the United States and abroad since the inception of vincristine use in the 1960s, this error is relatively rare. Still, it is unique in its level of mortality. Improvements in practice over the years, including manufacturer- and pharmacist-issued warning labels, have reduced the number of deaths, but the error continues to occur.
“Every medical center, hospital, and oncology practice that makes the commitment to ‘Just Bag It’ takes an important step toward patient safety and ensures that this error will never happen again,” Dr. Carlson said. “Christopher’s memory inspires us to never give up telling his story and remaining vigilant for this cause.”
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.
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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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