Transition to NRFit™ connectors for intrathecal and epidural procedures, and delivery of regional blocks

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. Transition should be completed by 31 January 2025.

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.

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 National Patient Safety Alerts

This alert has been issued as a National Patient Safety Alert.

The NHS England National Patient Safety Team was the first national body to be accredited to issue National Patient Safety Alerts by the National Patient Safety Alerting Committee (NaPSAC). All National Patient Safety Alerts are required to meet NaPSAC’s thresholds and standards. These thresholds and standards include working with patients, frontline staff and experts to ensure alerts provide clear, effective actions for safety-critical issues.

NaPSAC requires providers to introduce new systems for planning and coordinating the actions required by any National Patient Safety Alert across their organisation, with executive oversight.

Failure to take the actions required under any National Patient Safety Alert may lead to CQC taking regulatory action.

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