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Minimising Risks of Mismatching Spinal, Epidural and Regional Devices with Incompatible Connectors

Reference number
1326
Central Alert System (CAS) reference
NPSA/2011/RRR003
Issue date28 November 2011
Action date (if applicable) (date field)31 March 2012
DH Gateway reference
16815
TypeAlert
Please note: Where the NHS Evidence Accredited Provider logo is used NICE has accredited the process used by NPSA to produce its rapid response reports. Accreditation is valid from July 2010 to July 2015. More information on accreditation can be viewed at www.nice.org.uk/accreditation.
 

Spinal, epidural and regional devices, with non-luer compatible neuraxial connectors, that will not connect with intravenous equipment, are being placed on the market by industry in response to the NPSA Patient Safety Alert issued in 2009.*

 

Although the use of these devices will reduce the risks of wrong route errors, it is essential that effective controls are in place to minimise the risk of mis-selection and supply of devices with incompatible connectors that could cause delay in clinical procedures and harm patients.

 

The NPSA has recently received details of a patient safety incident, where a spinal needle with a neuraxial connector was supplied and used in error when a device with a Luer connector was required. The labelling and packaging of the two devices with Luer and neuraxial connectors, from the same manufacturer, looked very similar in their appearance. 

 

For IMMEDIATE ACTION by all organisations in the NHS and independent sector who use spinal, epidural and regional devices. Deadline for ACTION COMPLETE: 31 March 2012.

 

1. Alert healthcare staff who order, receive, transport, restock and clinically use spinal, epidural and regional devices of the risk of mis-matching connectors.

 

2. Check current stocks of spinal, epidural and regional devices to ensure these devices are compatible.

 

3. Amend written distribution and clinical procedures to confirm the identity of the connectors used in devices. Checks should not solely rely on catalogue code numbers. The term ‘Luer’ and where neuraxial connectors are fitted, the device trademark should be used to identify different connector designs. Currently Correctinject, Hall Lock, Neurax, Surety, UniVia are trademarks being used. Only devices with the same connector descriptors are compatible. In addition, other design elements such as colour, text and symbols should assist users to identify the type of connector used in the device.

 

4. Use procedure packs where feasible and appropriate to ensure that all the devices required for a specified procedure are compatible and readily available.

 

5. Recommend clinical staff check all devices required for a procedure are fitted with the same connector design before commencing the procedure.

 

* Safer spinal (intrathecal), epidural and regional devices:  NPSA/2011/PSA001 31 January 2011, NPSA/2009/PSA004B 24 November 2009, http://www.nrls.npsa.nhs.uk/resources/?EntryId45=94529

 

* Please note: From 1 June 2012 all enquiries related to alerts (Rapid Response Reports, Patient Safety Alerts, Safer Practice Notices etc) should be directed to the Central Alerting System Helpdesk: safetyalerts@dh.gsi.gov.uk.

 

 

Minimising Risks of Mismatching Spinal, Epidural and Regional Devices with Incompatible Connectors R
Minimising Risks of Mismatching Spinal, Epidural and Regional Devices with Incompatible Connectors R - 81 KB 1326 | Minimising Risks of Mismatching Spinal, Epidural and Regional Devices with Incompatible Connectors Rapid Response Report | 2011-11-28 | v1