4 | REGIONAL ANAESTHESIA | 2020
TABLE 1
Number , severity and route of drug administration errors caused by misconnection 1
Event severity scale Incident ( s ) Drug name Drug class Events ( n ) Low Moderate Severe Death Vincristine a , b Chemotherapy 19 4 15 Thiocolchicoside a Muscle relaxant 4 4
Potassium |
N / A |
6 |
5 |
1 |
chloride a
|
|
|
|
|
Bupivacaine Local anaesthetic 5 1 4 Tranexamic acid b Antifibrinolytic 2 1 1 Gadolinium c Contrast agent 3 1 2 Ropivacaine Local anaesthetic 3 1 2 Vecuronium a Muscle relaxant 3 1 2 Paracetamol a Pain reliever 2 1 1 Oxytocin N / A 2 2
Ephedrine a
Nonselective adrenergic agonist
2 2
Succinylcholine a General anaesthetic 2 2 Thiopental a General anaesthetic 2 2
It ’ s about sharing the message of the importance of [ NRFit™ ], why it ’ s needed and educating people with the new protocols and the requirements behind it Laura Mitchell
A summary of the literature review indicated the need for a solution to the incidence of misconnections :
• The number of occurrences is low : 1.3 – 2.7 % of all identified anaesthesia medical errors , which equates to 1.0 – 1.1 occurrences per 10,000 anaesthesia administrations
• However , the effects can be severe , leading to death
• Connection errors are largely preventable
• Chronic underreporting of misconnection errors is widely acknowledged
Introduction to ISO 80369-6 design standard for neuraxial applications connection ( NRFit™ ) There was unanimous familiarity with the ISO of not to 80369-6 standard across the Faculty , and Professor Benhamou recounted the background to its development .
There is no one system that can avoid all errors , and it is absolutely necessary to combine several systems . As an indication of the scale of the problem , it is estimated that 14 % of drug errors result from incorrect route of administration . Measures that have the potential to make systems less error prone and to enhance a culture of safety include organisational changes , communication and teamwork , teaching and research and audits . Those measures that are based on technology and equipment include the use of pre-filled syringes , international colour codes , calculators at bedsides , barcoding , the automatic recording of records and those functions that are obligatory . It was the NHS Patient Safety Alert 21 published in 2007 calling for safer practice with epidural injections and infusions that awakened healthcare professionals to the scale of the problem for RA . By 2011 , all intrathecal bolus doses and lumbar puncture samples using syringes , needles and other devices in the UK were not to be connected with intravenous Luer connectors . In 2013 this was extended to all RA systems , not only neuraxial but also peripheral neural blocks and infusion boluses . To allow for hospital implementation time , manufacturers were obliged to supply devices with safer connectors well before the required implementation date in 2017 . However , as we will see later , adoption by hospitals has been slow .
The ISO joint working group proposed the name NRFit™ to describe the 80369 series of non-Luer connectors . It is a series of different connectors , of which 80369-6 applies to all needles and syringes used for RA , encompassing spinal , epidural anaesthesia , combined spinal-epidural anaesthesia , peripheral nerve blocks and lumbar puncture . NRFit™ is colour coded yellow , reduces the risks of misconnections for neuraxial and regional blocks and is compatible between all manufacturers . ( This specific colour is not included in the definition if the 80369-6 series but is acknowledged by manufacturers and healthcare providers as being a useful adjunct which might provide additional safety benefit .) Research conducted by BD indicates that general attitudes