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New patient safety alert announced

A National Patient Safety Alert has been issued instructing all relevant NHS funded providers to transition to NRFit connectors for all intrathecal and epidural procedures, and delivery of regional blocks.

The NHS has long used a range of medical devices with the universal Luer connector to administer medicines via different routes of administration, including the intravenous, intrathecal and epidural routes.

This commonality of connector carries significant risk of accidental wrong route administration of medication. The potential for a fatal outcome from this is well known, especially if medication intended to be administered via a vein (intravenous administration) is wrongly injected into the spine (intrathecal or epidural administration). Previous patient safety alerts have been issued to support providers and staff to reduce this risk.

To overcome this issue a dedicated standard connector (NRFit) for procedures and medicines administration involving the intrathecal and epidural route was developed.  A full portfolio of these NRFit devices is now available for use across the NHS.

NRFit devices with this connector are not compatible with Luer connectors, reducing the risk of medication being delivered by the wrong route.  For example, medication prepared for intravenous administration in a syringe with a Luer connector cannot be accidentally connected to a device that will deliver the medicine via the intrathecal or epidural route, as the cannula (in the patient) will have a NRFit connector preventing connection.

This National Patient Safety Alert instructs all relevant NHS funded organisations to complete the transition to using these safer connectors by 31 January 2025,  for all intrathecal and epidural procedures and delivery of regional blocks.

Failure to take the actions required under any National Patient Safety Alert may lead to CQC taking regulatory action.

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Upcoming Events

Advancing Ultrasound Probe Decontamination Study Day

Horizon Leeds, 2 Kendall Street #3rd Floor Leeds LS10 1JR
12th March 2024

Webinar: How to be Compliant and Sustainable In Healthcare

ONLINE
19th March 2024 & 21st March 2024 10 am CET time o

POCT Innovators: The Power to Disrupt Series

Cloth Hall Court, Leeds. UK
20 March, 2024

Central Sterilising Club - Annual Scientific Meeting 2024

Crowne Plaza at Gerrard’s Cross
15th April 2024 – 16th April 2024

DECON UK 2024

National Conference Centre, Birmingham
17th April 2024

Infection Prevention & Control

National Conference Centre, Birmingham
23rd - 24th April 2024

Access the latest issue of Clinical Services Journal on your mobile device together with an archive of back issues.

Download the FREE Clinical Services Journal app from your device's App store

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