updated 7/25/2005 3:43:25 PM ET 2005-07-25T19:43:25

A rare but probably underreported drug mix-up involving a potent cancer drug can kill or permanently paralyze patients, and hospitals need to take precautions to avoid it, a health care accrediting group warned Thursday.

  1. Don't miss these Health stories
    1. Splash News
      More women opting for preventive mastectomy - but should they be?

      Rates of women who are opting for preventive mastectomies, such as Angeline Jolie, have increased by an estimated 50 percent in recent years, experts say. But many doctors are puzzled because the operation doesn't carry a 100 percent guarantee, it's major surgery -- and women have other options, from a once-a-day pill to careful monitoring.

    2. Larry Page's damaged vocal cords: Treatment comes with trade-offs
    3. Report questioning salt guidelines riles heart experts
    4. CDC: 2012 was deadliest year for West Nile in US
    5. What stresses moms most? Themselves, survey says

The drug vincristine is supposed to be injected into a vein but is sometimes accidentally added to spinal catheters used for different drugs in leukemia and lymphoma patients, the Joint Commission on Accreditation of Healthcare Organizations said in a safety alert.

Administering vincristine into the spine kills nerve cells and is usually fatal, said Andrew Seger, a research pharmacist at Boston's Dana-Farber Cancer Institute.

Seger said his research has found about 49 cases of vincristine mix-ups worldwide since 1968. About 90 percent of patients died, he said.

JCAHO's warning was sent to more than 4,500 hospitals the group accredits. Those that don't follow JCAHO's recommendations for avoiding the mix-up could risk losing accreditation.

Only one U.S. case, resulting in permanent paralysis, has been reported to JCAHO. The Institute for Safe Medication Practices has received voluntary information from doctors about six U.S. cases in 30 years, said Dr. Michael Cohen, institute president.

The most recent cases include the 2002 death of a 49-year-old New Jersey man while undergoing treatment for lymphoma.

Media reports suggest there may be others, raising concern that health care organizations "are choosing not to voluntarily report these fatal errors to JCAHO" out of fear of being sued, the JCAHO alert said.

It advised hospitals to make sure vincristine syringes are properly labeled with warnings that spinal injections are fatal, and that the drug is for intravenous use only.

Vincristine also should be given to patients at different times and in different rooms than drugs administered through the spine, the alert said.

"We need to be vigilant about this," Seger said. "I'm glad JCAHO has done down this path."

© 2013 The Associated Press. All rights reserved. This material may not be published, broadcast, rewritten or redistributed.

Discuss:

Discussion comments

,

Most active discussions

  1. votes comments
  2. votes comments
  3. votes comments
  4. votes comments