Transcription of LEARNING FROM ERROR - WHO
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LEARNING FROM ERROR - WHO
Patient Safety WorkshopLEARNING FROM ERRORWHO/IER/ World Health Organization 2008 All rights reserved. Publications of the World Health Organizationcan be obtained from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264;fax: +41 22 791 4857; e-mail: Requests forpermission to reproduce or translate WHO publications - whetherfor sale or for noncommercial distribution - should be addressed toWHO Press, at the above address (fax: +41 22 791 4806; The designations employed and the presentation of the materialin this publication do not imply the expression of any opinionwhatsoever on the part of the World Health Organizationconcerning the legal status of any country, territory, city or area orof its authorities, or concerning the delimitation of its frontiers orboundaries.))
Vincristine: what went wrong? Vincristine, a widely used chemotherapeutic agent, should only be administered intravenously and never by any other route. Many patients receiving intravenous vincristine also receive other medication via a spinal route as part of their treatment protocol. This has led to errors where vincristine has
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