Supply of neuraxial connector devices with incompatible devices

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Intravenous products: The NPSA report “Spinal, epidural and regional devices, with non-luer compatible neuraxial connectors, that will not connect with intravenous equipment, are being placed on the market by industry in response to the NPSA Patient Safety Alert issued in 2009.*

Although the use of these devices will reduce the risks of wrong route errors, it is essential that effective controls are in place to minimise the risk of mis-selection and supply of devices with incompatible connectors that could cause delay in clinical procedures and harm patients.

The NPSA has recently received details of a patient safety incident, where a spinal needle with a neuraxial connector was supplied and used in error when a device with a Luer connector was required. The labelling and packaging of the two devices with Luer and neuraxial connectors, from the same manufacturer, looked very similar in their appearance.

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