News Details
NCCN “Just Bag It!” Campaign Shoots for 100 Adopters by End of Annual Conference
[FORT WASHINGTON, PA - March 7, 2017] – By the time its annual conference concludes on March 25, 2017, the National Comprehensive Cancer Network® (NCCN®) is aiming to have 100 reported medical centers and practices that deliver chemotherapy committed to Just Bag It: The NCCN Campaign for Safe Vincristine Handling. NCCN will register new adopters prior to and during the NCCN 22nd Annual Conference: Improving the Quality, Effectiveness, and Efficiency of Cancer Care™ March 23-25 in Orlando, FL, and report progress toward the goal on Twitter: #NCCNac17 and #NCCNJustBagIt.
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 November 10, 2016 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.
Prior to the launch in November, all 27 NCCN Member Institutions had adopted policies in line with these Guidelines, which are also recommended by the Institute for Safe Medication Practices, the Joint Commission, the World Health Organization, and the Oncology Nursing Society.
By the end of February, more than 30 additional centers had confirmed with NCCN their adherence to the campaign, which NCCN is waging through social media and its 27 Member Institutions.
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, neurological defects, and eventually 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.
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.
“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.”
Surveys issued by the Institute for Safe Medication Practices (ISMP) show that over time, more hospitals have adopted a policy to always bag vincristine. According to ISMP data, the number of hospitals that have fully implemented the policy across their practice nearly doubled between February 2014 and February 2016. Earlier surveys indicated a similar increase between 2005 and 2012. Still, only about half of all respondents indicated that they have implemented the policy in all treatment settings, indicating that there is a long way to go.
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.
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 www.NCCN.org/JustBagIt.
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