Patient safety alert on non-Luer spinal (intrathecal) devices for chemotherapy

An NHS England patient safety alert has been issued today (20 February 2014) to all hospitals in England who administer spinal (intrathecal) chemotherapy, to minimise the risk of wrong route administration. The alert instructs hospitals to only use syringes and needles, and other devices, with non-Luer connectors when delivering this type of chemotherapy, as they cannot connect with intravenous devices.

If intravenous chemotherapy is administered into the spine it can result in death. Although no incidents of this kind have been reported in England since 2001, deaths have continued to be reported in Europe and worldwide.

A complete range of non-Luer devices is now available for spinal (intrathecal) bolus chemotherapy and many NHS trusts have already successfully implemented the use of these new devices. This patient safety alert follows on from previous alerts on non-Luer devices issued by the former National Patient Safety Agency.

Dr Mike Durkin, National Director of Patient Safety, NHS England, said: “The NHS in England is the first healthcare system in the world to have introduced these safer devices for spinal (intrathecal) chemotherapy. Although there have been no deaths in England caused by this kind of incident for over ten years it is vital to ensure we eliminate this risk to our patients.

“Patient safety alerts are a crucial part of our work to rapidly alert the healthcare system to risks and to provide guidance on preventing potential incidents that may lead to harm or death.”