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NPSA guidelines to accompany new spinal devices that protect patient safety

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A new rapid response report aims to cut the risk of nurses and doctors giving epidural or spinal drugs intravenously - or vice versa - by making sure incorrect devices will not fit connectors.

The National Patient Safety Agency (NPSA) report has gone to English and Welsh NHS bodies and aims to make sure the right safeguards are in place.

The medical device industry is offering spinal, regional and epidural devices that will not fit equipment that gives intravenous drugs after taking account of a 2009 patient safety alert from the NPSA. The newer devices have non-luer compatible neuraxial connectors.

The newly issued report adds to the guidelines offered in the safety alert. If doctors and nurses pick the wrong combinations patients could be hurt and the procedures they need will be held up.

Even though the new devices will cut the risk of a mix-up, it is important that ways of working that minimise the risk are used in hospitals and clinics.

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, NPSA head of patient safety - medication practice and medical devices said: “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.”



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