Fernandez C V, Esau R, Hamilton D, Fitzsimmons B, Pritchard S
Department of Pediatrics, British Columbia's Children's Hospital, Vancouver, Canada.
J Pediatr Hematol Oncol. 1998 Nov-Dec;20(6):587-90. doi: 10.1097/00043426-199811000-00022.
Accidental intrathecal vincristine instillation is usually a fatal error. The authors report an analysis of a patient and suggest means with which to reduce such errors.
A 7-year-old girl with recurrent acute lymphoblastic leukemia was inadvertently injected intrathecally with 1.5 mg vincristine. A detailed analysis of the events leading to this error and a review of all reported cases in the English literature were undertaken.
Reasons for errors reported by us and other institutions included mistaking vincristine for an intended intrathecal drug, assuming vincristine was an additional drug to be injected, not checking physician orders, mistaken route of administration, and mislabeling of syringes.
Intrathecal injection of vincristine may be the end-result of a series of systems errors. Protocol recommendations to reduce the likelihood of this error are presented.
鞘内误注长春新碱通常是致命性错误。作者报告了对一名患者的分析，并提出了减少此类错误的方法。
一名7岁复发性急性淋巴细胞白血病女童被意外鞘内注射了1.5毫克长春新碱。对导致该错误的事件进行了详细分析，并对英文文献中所有报告的病例进行了回顾。
我们及其他机构报告的错误原因包括将长春新碱误认为是预定的鞘内用药、认为长春新碱是要注射的附加药物、未核对医嘱、给药途径错误以及注射器标签错误。
鞘内注射长春新碱可能是一系列系统错误的最终结果。本文提出了减少此类错误发生可能性的方案建议。
