News

Resources to support safe transition from the Luer connector to NRFit™ for intrathecal and epidural procedures, and delivery of regional blocks

A resource alert has been issued to support providers to safely manage the transition from the Luer connector to NRFit™ for intrathecal and epidural procedures, and delivery of regional blocks.

Patient safety incidents are occurring due to the accidental administration of medication intended for intravenous use via a neuraxial device, and vice versa, resulting in the patient receiving drugs through the wrong delivery route, which in some cases has been fatal.

To prevent these errors a new dedicated connector for neuraxial and regional block devices – NRFit™ (ISO 80369-6:2016) has been developed and is now being introduced to the NHS. Devices with this connector are not compatible with Luer connectors, preventing the risk of drugs being delivered through the wrong route. Industry has now adopted this new ISO standard for use throughout the UK and NRFit™ is now the dedicated connector for neuraxial devices. The Surety® devices introduced as an interim safety measure while the new ISO standard was being developed will now be discontinued.

This alert supports providers with the safe transition from the Luer connector to NRFit™ for intrathecal and epidural procedures, and delivery of regional blocks. The alert signposts providers to the supporting information to help them recognise the risks to patients and to manage the process as safely as possible.

This supporting presentation explains the background behind this patient safety issue and Alert, and the need for a carefully planned transition to new NRFit™ safe connectors for neuraxial infusions.

Patient safety alerts are shared rapidly with healthcare providers via the Central Alerting System (CAS).

Related content