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Mary Ann Benitez

The World Health Organisation has issued a global alert on a widely used cancer drug after the death last month of a 21-year-old patient at Prince of Wales Hospital.

The alert, issued on Wednesday  last week,  warned that  vincristine  should only be administered intravenously as it would be fatal if given  any other way.

The WHO alert specifically referred to the case of a Hong Kong woman who died after being administered  the drug 'accidentally via spinal route in error'. The agency named the drug but the Hospital Authority  had only described  it as 'an intravenous chemotherapy drug'.

The  leukaemia patient died on July 7.   On June 20, the drug was injected into her spinal canal, which surrounds the spinal cord.

The doctor  remains suspended.  A panel that includes  Ian Tannock  from the University of Toronto, one of Canada's renowned oncologists,  is conducting an inquiry.  It will submit a report in one month.

The WHO said: 'Vincristine, a widely used chemotherapeutic agent, should only be administered intravenously, and never by any other route.'

It recommended that  a clear warning label  be put on the medication that reads: 'For intravenous use only - fatal if given by other routes'.

The WHO also recommended that syringes should not be used for administering vincristine. The drug should be prepared by dilution in small  intravenous bags to protect against accidental administration via a syringe.

In the long-term, the agency urged that hospitals should develop and promote the separation of intravenous and spinal delivery systems.

A spokesman for the Hospital Authority said  yesterday  it 'promptly informed WHO with relevant clinical details to facilitate their issue of the alert'.

Authority chief executive Shane Solomon  reiterated  the  blunder was 'a serious mistake'.

The WHO said 55 cases had been reported worldwide since 1968  of vincristine  being administered via a spinal route.

'There have been repeated warnings over time and extensive labelling requirements and standards,' it said in the alert. 'However, errors related to the accidental administration of vincristine via a spinal route continue to occur.'

Before the Hong Kong incident, the last known mishap occurred in the United States in November 2005. A 21-year-old man being treated for non-Hodgkin's  lymphoma received an injection via the spinal route when a syringe of vincristine for another patient was accidentally delivered to  his bedside.

The error was not recognised and the patient died three days later, the WHO said.

In Spain, a 58-year-old woman with  the same cancer died in October 2005, 100 days after receiving the medication. The doctor realised the error after 2ml of the medicine was  injected  into her.

In Australia, a 28-year-old man with Burkitt's lymphoma  died 28 days after vincristine was  injected into his spinal canal in 2004. The warning label on the  drug was incomplete and in small print.



Death at Prince of Wales prompts  global warning over cancer drug