Vincristine is a cytotoxic chemotherapy agent classified as an antitumor alkaloid and is part of the vinca alkaloid family. Vincristine’s mechanism of action is to primarily inhibit mitosis of the cancer cell and is given by IV route only for treatment. Accidental intrathecal administration of vincristine has lethal consequences for patients. To minimize the risk of accidental intrathecal administration of vincristine, 14 infusion centers participated in a quality improvement project to change the practice of vincristine administration from IV push to IV piggyback via minibag and gravity. After three months, all infusion centers successfully implemented the practice.