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Please note that NPSA/2009/PSA004A issued on 29 November 2009 has been superceded in order to change the Alert implementation date from 1 April 2011 to 1 April 2012 and update the list of actions.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