A National Patient Safety Alert has been issued by the NHS England National Patient Safety Team, co-badged by the Association of Anaesthetists, Royal College of Anaesthetists and the Safe Anaesthesia Liaison Group, instructing all relevant NHS funded providers to transition to NRFit™ connectors for all intrathecal and epidural procedures, and delivery of regional blocks.
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.
About this alert
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.