NPSA Rapid Response Report on spinal connectors

29th December 2011

The UK National Patient Safety Agency (NPSA) have issued a Rapid Response Report on minimising risks of mismatching spinal, epidural and regional devices with incompatible connectors (NPSA/2011/RRR03).  NPSA have quoted a recent 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. 

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 (NPSA/2009/PSA004A) and updated in January 2011 (NPSA/2011/PSA001). 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 that could cause delay in clinical procedures and harm patients.

The RRR provides additional guidance to the original patient safety alert, on minimising the risk of mis-selecting incompatible connectors, with a deadline for action complete of 31 March 2012.

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