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. 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.
