National Patient Safety Alert – Transition to NRFit™ connectors for intrathecal and epidural procedures, and delivery of regional blocks

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This 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.

Please note the following updated links to the NHS Wales video resources referred to in the Alert: general specialties and anaesthetics.

Update: 31 January 2025

This National Patient Safety Alert was issued to ensure that the risk of misconnection and wrong route error is reduced by implementing the design solution as per ISO 80369-6.

Issuing the alert has driven significant change in product availability and consequently safer NHS care.

However, we appreciate that, even with the 12-month compliance date, there will be a few areas of practice where it is not possible to legitimately transition to a direct alternative with NRFit™ connectivity.

Suppliers to the NHS (including NHS Supply Chain) can provide support in sourcing NRFit™ devices and the Safe Anaesthetic Liaison Group (SALG) has produced an FAQs webpage to provide professional support in relation to which procedures fall within the remit of the alert and to support clinical queries.

New queries can be submitted via email to admin@salg.ac.uk.

In addition, organisations may wish to share insight into how they have implemented the alert and what products they have sourced with other organisations via their clinical procurement specialist (CPS) and medical device safety officer (MDSO) to ensure the sharing of good practice.

Declaring compliance

Organisations can declare compliance with the alert if:

  • the organisation has made every effort to source appropriate NRFit™ products for all procedures
  • the organisation has identified that no NRFit™ compatible product is currently available
    and/or
  • a national professional organisation has determined that the NRFit™ alternative is not suitable (for example, Statement on Caudal Anaesthesia and NRFit | APAGBI)

Where an organisation has identified that procedures need to continue using products with luer connections they should:

  • log the need for a NRFit™ compatible device with NHS Supply Chain or direct to manufacturers
  • undertake a risk assessment and introduce other mitigations where appropriate
  • add each procedure to the organisations risk register and ensure an annual review, to check if suitable NRFit™ products have become available
  • ensure continuation to undertake appropriate procedures using products with luer connections has been signed off at a board-reporting committee

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National Patient Safety Alert - Transition to NRFit™ connectors for intrathecal and epidural procedures, and delivery of regional blocks

National Patient Safety Alert - Transition to NRFit™ connectors for intrathecal and epidural procedures, and delivery of regional blocks

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