This page is part of the wider ‘Aspects of previous patient safety alerts that should inform broader local safety initiatives’ set of webpages.
Connectors to reduce the risk of wrong-route enteral, intravenous, and spinal/intrathecal administration
Past alerts required the adoption of interim solutions or provided advice to reduce risk during periods of transition to new international standards of equipment that engineer out the potential for misconnection.
The availability of internationally standardised connectors such as ENFit® and NRFit® has been a significant advance in patient safety, although providers still need to ensure managed and enduring procurement of such products across all settings to ensure this is embedded as routine practice.
Previous alerts highlighted the requirement for certain medicines to be available in a ready-to-administer presentation to improve safety; for example, epidural infusions, insulin syringes for continuous insulin infusions and high-risk injectable products. However, undertaking risk assessments and selecting medication presentations that will reduce the risk of error, as outlined in the ‘Promoting safer use of injectable medicines alert’, is a principle that applies to all medications administered within healthcare.
Organisations should focus on the wider context of a purchasing for safety agenda. This should consider the general principles of simplifying and rationalising the range and presentation of all medicines, including the provision of ready-to-administer or ready-to-use injectable products.
Any purchasing for safety work should also consider the potential for unintended consequences from the decisions made. For example, while the increased use of pen devices for the administration of insulin has undoubtedly made it much easier for patients to self-inject, significant and potential fatal overdosing incidents have arisen from staff extracting insulin directly from the pen or cartridge.
Go back to the main ‘Aspects of previous patient safety alerts that should inform broader local safety initiatives’ webpage.