Deaths reported from the accidental intrathecal administration of bortezomib

Peter Gilbar, Andrew C Seger

Medication errors due to the inadvertent intrathecal administration of vincristine and other antineoplastic agents continue to occur despite the development of preventative strategies. Three fatalities due to bortezomib being accidentally given intrathecally instead of by the intended intravenous route have recently been reported by the European Medicines Agency. The most effective method for preventing accidental intrathecal administration is to eliminate the syringe as a means of administrating neurotoxic agents and prepare them in a small volume minibag. However due to a lack of stability data for bortezomib in a minibag and the increasing use of bortezomib via the subcutaneous route necessitates the continued preparation of bortezomib in a syringe. A number of recommendations aimed at preventing the possibility of accidental intrathecal administration of bortezomib are made. These need to be incorporated into standard practice internationally and pharmacists must take the lead to ensure this occurs as a matter of urgency.