A patient in error has an IV medication injected into his spinal canal and then learns that there is no cure for the error and that he will die a painful death usually within days. What a horrible medication error for a nurse or physician to have to live with. every day.
The ISMP error newsletter has a very good article on the erroneous intrathecal (via the spinal route) administration of IV vinca alkaloids, primarily vinCRIStine. The article has helpful hints regarding this error and other medication errors. Nurses should be reading every issue of this newsletter to help protect patients.