ABSTRACT
Evidence regarding the hazards of inadvertent intrathecal vincristine administration errors was available at the time of this event (Noble and Donaldson 2010). Within days of the tragedy described above, The Joint Commission – then called the Joint Commission on Accreditation of Healthcare Organizations, or JCAHO – released information in an alert to warn the industry about errors involving administration of vincristine into the spine (Joint Commission 2005).
