Nov 10, 2016 10:00 AM

Just Bag It

SALT LAKE CITY—As part of its ongoing commitment to patient safety, Huntsman Cancer Institute (HCI) at the University of Utah is standing with a national campaign to end a dangerous chemotherapy error. Just Bag It: The NCCN Campaign for Safe Vincristine Handling, launched today by the National Comprehensive Cancer Network® (NCCN®), encourages health care providers to adopt a policy to always dilute and administer the medication vincristine in a mini IV-drip bag to prevent the improper administration of the drug.

Together with each of NCCN’s 27 members, HCI has adopted a policy in line with this recommendation, and is calling on other medical centers around the nation and world to join suit. NCCN is an alliance of the nation’s leading cancer centers that collaboratively develops the cancer treatment guidelines that set the standard of care around the world to improve the quality, effectiveness, and efficiency of cancer care so that patients can live better lives. HCI has been a member of NCCN since 1997.

Vincristine is a chemotherapy agent, widely used in patients with leukemia or lymphoma, which is administered intravenously, or directly into the patient’s vein. When it enters the blood, it is highly effective at blocking the growth of cancer by preventing cells from separating. However, vincristine is a neurotoxin that causes peripheral neuropathy when given intravenously and profound neurotoxicity if given into the spinal fluid, which flows around the spinal cord and brain.

The problem occurs because many patients who receive vincristine have a treatment regimen that includes other chemotherapy drugs that are injected into the spinal fluid with a syringe. If vincristine is mistakenly administered into the spinal fluid, it is uniformly fatal, causing ascending paralysis, neurological defects, and eventually death.

“It is our collective responsibility to end this tragic and preventable error once and for all,” said Scott Silverstein, MS, RPh, HCI director of pharmacy. “Taking part in this campaign is the latest of our long-standing efforts to improve patient safety. We are proud to stand with NCCN in encouraging every hospital that treats patients with cancer to ‘just bag it.’”

HCI’s policy to use a mini IV-drip bag, and never a syringe, to administer vincristine renders it impossible to accidentally administer the medication into the spinal fluid and greatly decreases the chances of improper administration. In addition to being supported by NCCN and all of its member centers, this policy is recommended by leading medical organizations including the Institute for Safe Medication Practices, the Joint Commission, the World Health Organization, and the Oncology Nursing Society.

Surveys issued by the Institute for Safe Medication Practices (ISMP) show that over time, more hospitals have adopted a policy to always bag vincristine. According to ISMP data, the number of hospitals that have fully implemented the policy across their practice nearly doubled between February 2014 and February 2016. Earlier surveys indicated a similar increase between 2005 and 2012. Still, only about half of all respondents indicated that they have implemented the policy in all treatment settings, indicating that there is a long way to go.

With 125 known cases of accidental death in the United States and abroad since the inception of vincristine use in the 1960s, this error is relatively rare. Still, it is unique in its level of mortality. Improvements in practice over the years, including manufacturer- and pharmacist-issued warning labels, have reduced the number of deaths, but the error continues to occur and cases have been reported in the United States as recently as 2011.

Diluting vincristine into a mini IV-drip bag may entail a change in practice for some providers, but it is well worth the outcome of avoiding preventable deaths, according to Robert W. Carlson, MD, CEO of NCCN. “One more life lost is one too many. We are thankful to HCI and all of our member institutions for joining us in the effort to end this devastating error for good.”

For more information about Just Bag It: The NCCN Campaign for Safe Vincristine Handling, visit

About the National Comprehensive Cancer Network

The National Comprehensive Cancer Network® (NCCN®), a not-for-profit alliance of 27 of the world’s leading cancer centers devoted to patient care, research, and education, is dedicated to improving the quality, effectiveness, and efficiency of cancer care so that patients can live better lives. Through the leadership and expertise of clinical professionals at NCCN Member Institutions, NCCN develops resources that present valuable information to the numerous stakeholders in the health care delivery system. As the arbiter of high-quality cancer care, NCCN promotes the importance of continuous quality improvement and recognizes the significance of creating clinical practice guidelines appropriate for use by patients, clinicians, and other health care decision-makers.

Media Contact

Heather Simonsen
Public Relations – Huntsman Cancer Institute
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About Huntsman Cancer Institute at the University of Utah

Huntsman Cancer Institute at the University of Utah is the official cancer center of Utah and the only National Cancer Institute-designated Comprehensive Cancer Center in the Mountain West. The campus includes a state-of-the-art cancer specialty hospital and two buildings dedicated to cancer research. Huntsman Cancer Institute provides patient care, cancer screening, and education at community clinics and affiliate hospitals throughout the Mountain West. It is consistently recognized among the best cancer hospitals in the country by U.S. News and World Report. The region’s first proton therapy center opened in 2021 and a major hospital expansion is underway. Huntsman Cancer Institute is committed to creating a diverse and inclusive environment for staff, students, patients, and communities. Advancing cancer research discoveries and treatments to meet the needs of patients who live far away from a major medical center is a unique focus. More genes for inherited cancers have been discovered at Huntsman Cancer Institute than at any other cancer center, including genes responsible for breast, ovarian, colon, head and neck cancers, and melanoma. Huntsman Cancer Institute was founded by Jon M. and Karen Huntsman.

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