Case 1: Two patients were to receive intrathecal methotrexate
with fluoroscopic guidance, Patient A in the morning and Patient
B in the afternoon. The pharmacist dispensed the two methotrexate
doses and the syringe for Patient A was delivered to his ward
that morning. However, the syringe was not delivered before
Patient A was transported to radiology. When Patient A arrived in
the radiology suite, the technician called over to pharmacy
looking for Patient A’s medication. In the pharmacy, the tech saw
a single syringe labeled for intrathecal use and delivered it to
radiology. This error was discovered when the pharmacist made
afternoon deliveries and saw that Patient A’s syringe was still
on the ward even though Patient A had already returned from the
procedure. Patient A had received Patient B’s medication.
Case 2: Chemotherapy agents were given via the intrathecal
route by the radiologist without verifying the order. Cytarabine
was given intrathecally, but ordered subcutaneously.
Case 3: Methotrexate intrathecal was sent to radiology for
administration instead of intrathecal cytarabine. The error was
detected before starting the procedure.
Fifty years after the first death from accidental injection of
the wrong chemotherapy agent intrathecally, we continue to
struggle with ensuring that these accidents do not recur. Wrong
medication errors for intrathecal chemotherapy fortunately are
rare, but, when they occur, can have severe consequences. None of
the above cases resulted in significant harm. They serve as
warning signals that our defenses against such events need
It is particularly important to pay attention to near misses and
minor events in settings where the potential for harm is rare and
extreme. “As systems become safer, it becomes progressively more
difficult to detect the remaining vulnerabilities.” (Franklin et
Discussions with CHPSO members and review of the CHPSO event
database identified the following challenges with intrathecal
It is difficult for the person performing the lumbar puncture
to scan the syringe barcode just before administration, as
his/her hands are engaged in performing the procedure.
Bar code medication administration may not be implemented yet
in the radiology suite.
Missing orders can result in time pressure for the
pharmacist, something that should be avoided for any chemotherapy
Patients receiving chemotherapy often receive both
intravenous and intrathecal chemotherapy the same day.
A long free-text chemotherapy order may be truncated by some
Defense in depth is required for protection against intrathecal
chemotherapy errors. The reference by Franklin et al describes
the typical measures taken in UK hospitals and is worth
reviewing. In addition to those measures, designing processes
that make bar code scanning occur reliably during intrathecal
procedures is important. However, while bar code medication
administration does help with wrong patient or wrong time errors,
it is not a strong protection for wrong-route errors. A correct
scan is not assurance that the drug should be given
Ultimately, the new NRFit connector, designed so that intravenous
syringes are not interconnectable with intrathecal or other
neuraxial devices, will provide an additional layer of
protection. Supply may not be sufficient yet for change-over, and
hospitals should check with their suppliers before starting the
transition. The main barrier to the change currently appears to
be supply of infusion sets needed for continuous labor epidurals.
Infusion sets should come into the market late this year.