Non-Cytotoxic Intrathecal and Intraventricular Injections (NCIII)
This page was last updated on 24/06/2026
Key Points:
- This policy must be rigidly adhered to at all times, as administration of the wrong medicine or dose by the intrathecal or intraventricular route could be potentially fatal.
- All members of staff involved in any way with the use of NCIIIs, must be formally approved and deemed competent for the task(s) involved.
- All specialties and medicines used via the intrathecal or intraventricular routes must be formally approved and documented in the NHSGGC NCIII Register of approved agents.
- Any practitioner wishing to use a new NCIII via the intrathecal or intraventricular route, or in a dose or within a clinical area not yet formally authorised, must make an application in writing via an SBAR to the co-leads for the policy (noted below) in advance of use.
- Deviations from the controls and details outlined in this Policy and Register are not permitted. If a situation arises where you consider you cannot comply with any aspect of the policy, this must be escalated to the joint-leads for the NCIII Policy and your Clinical Director or Chief of Medicine for further discussion.
NCIII policy (approved March 2026) and NCIII Registers
Preparation and administration of intrathecal and intraventricular (intracerebroventricular) injections is a hazardous process and is associated with a significant number of potentially serious patient safety risks. The intrathecal or intraventricular route should therefore only be used where there is a clear body of evidence of efficacy, or as part of a clinical trial.
The safe use of intrathecal and intraventricular injections is a high priority requiring stringent risk management. As a result, the Scottish Executive Health Department issued HDL(2006)11 – Guidance on the Safe Handling of Intrathecal and Intraventricular Injections in February 2006 for Non-Cytotoxic Intrathecal and Intraventricular Injections (NCIIIs) and requested full implementation of this national guidance with immediate effect. The recommendations contained within this document have numerous implications and build on the recommendations of two previous publications: HDL(2004)30 Guidance on the Safe Administration of Intrathecal Cytotoxic Chemotherapy, and the Clinical Resource and Audit Group (CRAG) Good Practice Statement on the Preparation of Injections in Near-Patient Areas, including Clinical and Home Environments, December 2002 (now archived but PDF available here).
This NHSGGC NCIII Policy was produced in response to HDL(2006)11 and was based on the NHSGGC Cytotoxic Intrathecal Chemotherapy Policy. All medicines used within NHSGGC via these routes must be formally requested, approved for use and be recorded in the NHSGGC NCIII Register. Adherence to this document will minimise the risk to patients receiving intrathecal or intraventricular injections within the hospitals of NHSGGC. Refer to the full NCIII Policy for full details
For any questions, or for support to process an application to add a new agent to the NHSGGC NCIII Register (or to amend the register for an existing agent), please contact:
Joint-leads for implementation of NCIII policy:
- Catherine McLaughlin, Lead Pharmacist, Medicines Governance
- Dr Jonathan McGhie, Consultant in Anaesthesia and Pain Medicine
Deputy leads for implementation of NCIII policy:
- Dr Myra McAdam, Consultant Anaesthetist, Anaesthesia & Theatres
- Lorna Rankine, Senior Pharmacist, Medicines Governance
- Rhona Shannon, Lead Pharmacist, Medicines Governance
- Colette Byrne, Lead Pharmacist, Medicines Support Service
Clinical trials lead pharmacist:
- Samantha Carmichael, Lead Pharmacist, Clinical Trials / Research & Innovation
NCIII Registers
The following registers record the specialties / clinical areas, NCIIIs, dose ranges and upper limits which are authorised for use within NHSGGC. This information is not transferable to other clinical areas and no other medicines can be used via the intrathecal or intraventricular (intracerebroventricular) route if not recorded in these registers under the relevant area.
If you would like to use a particular medicine via the intrathecal or intraventricular route which is not on this list and within your own area, you must submit a request in writing in advance of use in the form of an SBAR, with supporting evidence and with an Unlicensed Medicines Request form (where appropriate) to the Designated Lead for the specialty / clinical area and the Leads for Implementation (above). The Designated Lead should consult with nominated pharmacy and nursing leads before making a decision on whether to approve / not approve the request. This decision will be formally authorised by the appropriate Chief of Medicine / Clinical Director, who retains overall responsibility. Refer to section 3.7.1 of the policy for further details. This application must be copied to Catherine McLaughlin or Dr Jonathan McGhie, or deputies (contact details above).