Aim
To prevent catastrophic wrong‑route neuraxial medication/solution administration by promoting a planned statewide implementation of ISO 80369‑6–compliant neural connectors (NRFit®) across Victorian hospitals.
Background
Drug errors involving “wrong-route” administration of substances into the central nervous system can have devastating consequences (see Iqbal et al for an example with an Australian context). Similarly, inadvertent intravenous administration of local anaesthetics can cause seizures, cardiac arrhythmias, or death. In 2016, a small-bore connector was developed to decrease the risk of this type of “wrong-route” medication error and specified this as an international standard (ISO 80369-6:2016, also described as NRFit®). An analysis of neuraxial drug errors in the Australian and New Zealand Tripartite Anaesthetic Data Committee database suggested that 80% of reported neuraxial errors would have been avoided if the NRFit® connection system had been in place (unpublished, personal communication).
The transition to NRFit® has been endorsed by the Australian Commission on Safety and Quality in Health Care (ACSQHC) and the Australian and New Zealand College of Anaesthetists (ANZCA). Given the logistic complexity of the changeover process, ANZCA have also produced resources to guide implementation. These resources outline manufacturer plans to cease production of legacy Luer products in the future. Uptake in Victorian hospitals trails other jurisdictions. This may introduce risks of future supply constraints and time-pressured transition should the current connectors be discontinued.
Recommendations
The Anaesthetic Subcommittee of the Victorian Perioperative Consultative Council strongly recommends that Victorian hospitals implement a plan for the introduction of NRFit® as soon as is practical.
References
Iqbal, I.M., Morris, R. and Hersch, M., 2018. Adhesive arachnoiditis following inadvertent epidural injection of 2% chlorhexidine in 70% alcohol—partial recovery over the ensuing eight years. Anaesthesia and Intensive Care, 46(6), pp.572-574.
ISO 80369-6:2016 neural connector devices to reduce misconnection errors
https://www.anzca.edu.au/safety-and-advocacy/standards-of-practice/neural-connector-changeover