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June 2012, Volume 42 Number 6 , p 16 - 16


  • Michael R. Cohen ScD, MS, RPH


At least three medication errors associated with the inadvertent administration of the I.V. antineoplastic drug bortezomib into the intrathecal space have been reported in Europe since 2003. Although the FDA has received no such reports in North America, the same risk exists here.In all three reported cases, misadministration of bortezomib occurred when intrathecal chemotherapy or another intrathecal drug was scheduled on the same day and at the same time as I.V. bortezomib therapy. Intrathecal chemotherapy and I.V. bortezomib are both administered in small volumes via small syringes, creating a condition favorable to error. Health Canada and Janssen, Inc., the manufacturer of bortezomib, have issued an alert recommending that intrathecal therapies be scheduled at a different time than other parenteral chemotherapy. Don't rely on syringe labeling alone, as similar errors involving vinca alkaloids (such as vinCRIStine) have occurred despite proper syringe labeling.In some healthcare settings,

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