Under new guidance from the National Patient Safety Agency (NPSA), from April 1, 2012, all NHS and other healthcare organisations are to begin using safer connectors when performing spinal (intrethecal) bolus doses and lumbar puncture samples.
These new connectors cannot connect with intravenous equipment. The NPSA issued an alert in 2009, pinpointing problems with the Luer connectors in causing fatalities when intravenous medicines had been administered by the spinal (intrathecal) route and epidural medicines had been administered by the intravenous route.
Luer connectors also allowed for medicines for regional anaesthesia to be administered through the intravenous route, which can also result in fatalities.
Medical devices, like the proposed connectors, which do not connect with intravenous equipment, will help reduce the risk of wrong route epidural incidents.
This is Part A of the Patient Safety Alert issued by the NPSA, with Part B due to follow on April 1, 2013, when all epidural, spinal (intrethecal) and regional infusions and boluses will also be performed with the new connectors.
The change is occurring in two parts to allow time for the replacement of the connectors and to help organisations with funding for the new connectors. The NPSA is also working with NHS Supply Chain and Welsh Heath Supplies to collate the costs of the new devices.
The NPSA advise clear labelling of the new devices with safer connectors, and recommend not using the word ‘neuraxial’ as it is not always clearly understood by all healthcare staff. The report suggests the use of the colour yellow to symbolise that the device is not to be used for the intravenous route, as it is already widely used by manufacturers and practitioners.
The Patient Safety Alert issued in January 2011 supercedes the alert issued in 2009, altering the start date of Part A from April 2011 to April 2012.
