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National Patient Safety Agency
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Minimising Risks of Mismatching Spinal, Epidural and Regional Devices with Incompatible Connectors

Monday 5 December 2011

 

The National Patient Safety Agency (NPSA) has issued a Rapid Response Report for NHS organisations in England and Wales, aimed at ensuring that effective controls are in place to minimise the risk of mismatching spinal, epidural or regional devices with incompatible connectors.

 

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.* This latest Rapid Response Report provides additional guidance to the Patient Safety Alert.

 

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. Mis-selection can cause delay in clinical procedures and in some circumstances could result in harm to patients.

 

The Rapid Response Report asks all organisations in the NHS and independent sector that use spinal, epidural and regional devices to:

 

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

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

  • Amend written distribution and clinical procedures to confirm the identity of the connectors used in devices.

  • Use procedure packs to ensure that all the devices required for a specified procedure are compatible and readily available.

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

 

Professor David Cousins, Head of Patient Safety- Medication Practice and Medical Devices, National Patient Safety Agency, said:

 

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.

 

“NHS staff should be made aware of the risk of mismatching connectors. The actions in this Rapid Response Report provide essential controls to prevent delay to clinical procedures, averting adverse outcomes.”

 

The NPSA has alerted devices manufacturers of this risk and will promote the need for safer design of labelling and packaging to clearly indicate the type of connector used in these devices.

 

View the Rapid Response Report, Minimising Risks of Mismatching Spinal, Epidural and Regional Devices with Incompatible Connectors.

 

* This guidance is for use in addition to the Patient Safety Alert Safer spinal (intrathecal), epidural and regional devices: NPSA/2011/PSA001 31 January 2011, NPSA/2009/PSA004B 24 November 2009.

 

 


 

Notes to editors

 

1.         Media enquiries to Matthew Grek in the NPSA Press Office:

 

            020 7927 9362 / press.office@npsa.nhs.uk

 

2.      Following the publication of the Arms Length Body Review on 26 July 2010, the NPSA has stressed the importance for all NHS organisations across England and Wales to continue reporting patient safety incidents through the National Reporting and Learning System.

 

3.      The national function for patient safety will continue within the NHS Commissioning Board and tools, guidance and support will be available to lead improvements in patient safety. A key role of the NHS Commissioning Board will be oversight of the National Reporting and Learning System which will continue to capture, analyse and feedback patient safety incidents to the NHS.