NHS Greater Glasgow & Clyde Area Drug and Therapeutics Committee
Greater Glasgow and Clyde Medicines
Medicines Update Acute

Intrathecal/Intraventricular Administration of Medicines (December 2014)

Definitions:

Intrathecal injection: often simply called an "intrathecal" or a “spinal”, an intrathecal injection is an injection into the spinal canal (intrathecal space surrounding the spinal cord).

Intraventricular injection:  injection of a drug for diffusion throughout the ventricular and subarachnoid space by means of ventricular puncture.

 

Background

Intrathecal and intraventricular injections are effective and appropriate methods of drug delivery for specific medicines and situations.  However, there are serious risks associated in administering medicines via these routes.  Some medicines should never be administered this way.  For example there have been a number of cases reported worldwide where the neurotoxic vinca alkaloid, vincristine, has been accidentally administered via the intrathecal route resulting in death or serious paralysis.

Safe administration of medicines via these routes is a high priority for the government and for NHSGGC.  Due to the potential risks involved, the NHSGGC intrathecal chemotherapy policy and the  non-cytotoxic intrathecal and intraventricular injection policy mandate stringent controls over how intrathecal therapy is prescribed, prepared, stored, delivered and administered.  Staff may only be involved with the use of these agents if formally trained and authorised to do so.  Such authorisation must be documented in the appropriate intrathecals register and regular competency review is necessary.  The responsibility for policy implementation in each specialty area lies with the Designated Lead Consultant.  Deviations from the stipulated controls can expose adults and children to unacceptable risks, including serious harm and death.  Within NHSGGC, a number of incidents and policy lapses have highlighted the need to reinforce some important learning points. 

Learning from incidents:

Case Study

Intravenous vincristine preparation was delivered to a theatre where a patient was prepared for the administration of intrathecal methotrexate.  Intrathecal administration of the intravenous vincristine injection would most likely have resulted in death or serious paralysis.  The causes of this incident were twofold: 

  1. Failure to follow strict processes for receipt of intrathecal therapy.  Intravenous vincristine was accepted by a member of medical staff from a member of pharmacy staff.  This handover took place in an area where there was no facility for any of the necessary checks to be carried out and no signature was provided. 

  2. Poor communication between the two members of staff.  Neither the patient’s name nor the name of the medicine was discussed during the handover.  This meant that only one member of staff was aware that an intrathecal medicine was involved.

In this case, additional process controls by vigilant and well-trained staff ensured patient harm was prevented. 

This was a serious incident where catastrophic consequences were only narrowly avoided. A review identified other incidents where NHSGGC intrathecal policies had not been followed.  These included incidents where products had to be discarded and/or treatment was delayed due to labelling errors or preparation by an unauthorised staff member.  While these incidents did not come as close to potentially harming a patient they nevertheless demonstrated lack of adherence to the controls relating to intrathecal use.

Key Messages

  • Be aware of the risks associated with intrathecal and intraventricular injections.  Stringent NHSGGC policies apply and deviations from policy are not acceptable.
  • Only authorised staff may prescribe, prepare, issue or administer intrathecal or intraventricular injections.
  • Immediate reporting of all incidents is imperative (via senior manager and Datix).
  • Remember:  Lack of adherence to intrathecal policies could be fatal.