Patient Safety Alerts are shared rapidly with healthcare providers via the Central Alerting System (CAS).
About this Alert
Patient safety incidents are occurring due to the accidental administration of medication intended for intravenous use via a neuraxial device, and vice versa, resulting in the patient receiving drugs through the wrong delivery route, which in some cases has been fatal.
To prevent these errors a new dedicated connector for neuraxial and regional block devices – NRFitTM (ISO 80369-6:2016) has been developed and is now being introduced to the NHS. Devices with this connector are not compatible with Luer connectors, preventing the risk of drugs being delivered through the wrong route. Industry has now adopted this new ISO standard for use throughout the UK and NRFitTM is now the dedicated connector for neuraxial devices. The Surety® devices introduced as an interim safety measure while the new ISO standard was being developed will now be discontinued.
This alert supports providers with the safe transition from the Luer connector to NRFit™ for intrathecal and epidural procedures, and delivery of regional blocks. The alert signposts providers to the supporting information below to help them recognise the risks to patients and to manage the process as safely as possible.
Information for NHS providers to support safe transition from the Luer connector to NRFit™ for intrathecal and epidural procedures, and delivery of regional blocks.
Supplier user guides and implementation guidelines are also available on the Barema - Association of Anaesthetic& Respiratory Equipment Suppliers website