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Safer spinal (intrathecal), epidural and regional devices

Reference number
1310
Central Alert System (CAS) reference
NPSA/2011/PSA001
Issue date31 January 2011
Action date (if applicable) (date field)01 April 2012
DH Gateway reference
15516
TypeAlert

There have been fatal cases where intravenous medicines have been administered by the spinal (intrathecal) route, and where epidural medicines have been administered by the intravenous (vein) route. There is also the potential for medicines intended for regional anaesthesia to be administered by the intravenous route, with fatal outcomes.

 

This Patient Safety Alert builds on previous safe practice guidance to further minimise the risk of these wrong route errors.

 

All NHS healthcare organisations are asked to ensure that:

 

from 1 April 2012 all spinal (intrathecal) bolus doses and lumbar puncture samples are performed using syringes, needles and other devices with connectors that cannot connect with intravenous Luer connectors (Part A).


from 1 April 2013 all epidural, spinal (intrathecal) and regional infusions and boluses are performed with devices that use safer connectors that cannot connect with intravenous Luer connectors or intravenous infusion spikes (Part B)


This Patient Safety Alert is being issued in two parts to allow two separate timescales for implementation.

 

Please note that NPSA/2009/PSA004A issued on 29 November 2009 has been superceded in order to change the Alert implementation date from 1 April 2011 to 1 April 2012 and update the list of actions.

 

Information on the reasons for changing the implementation date is provided on the Alert.

 

A series of Neuraxial Update Newsletters, are available to download from Patient Safety First.

 

A neuraxial forum and discussion group is also available from Patient Safety First.

 

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.

 

 

Safer spinal (intrathecal), epidural and regional devices - Part A update
Safer spinal (intrathecal), epidural and regional devices - Part A update - 574 KB 1310 A | Safer spinal (intrathecal), epidural and regional devices - Part A update | 2011-01-27 | v1
Safer spinal (intrathecal), epidural and regional devices - Part B
Safer spinal (intrathecal), epidural and regional devices - Part B - 201 KB 0927B | Safer spinal (intrathecal), epidural and regional devices - Part B | 2009-11-24 | v1
Safer spinal (intrathecal), epidural and regional devices supporting information
Safer spinal (intrathecal), epidural and regional devices supporting information - 240 KB 1310 C | Safer spinal (intrathecal), epidural and regional devices supporting information | 2011-01-27 | v2