Latest News
  • 25/03/2014 Goodbye to the old website...

    more...
  • 13/03/2014 Celebration of Life - Professor Sanjay Datta MBBS

    more...
  • 14/12/2013 Website Upgrade

    more...

NPSA Safer spinal, epidural and regional devices

 

 

Needle evaluation OAA / SALG

 

 

Monitoring of adverse outcomes at CS / NOAD

 

 

 

Contents of this page

NPSA Alerts / Documents and communications / NPSA newsletters / Published evaluations

Currently it is possible to inject drugs intended for intravenous administration into the spinal or epidural space and conversely to inject drugs intended for spinal, epidural or regional nerve block via the intravenous route. This has occasionally resulted in fatalities and continues to feature in patient safety incident reports.

The NPSA wished NHS organisations to change to equipment with non-Luer connections for chemotherapy in 2014.

Patient Safety Alert on non-Luer spinal (intrathecal) devices for chemotherapy

Click here to view Alert

Click here to view Supplementary information

http://www.england.nhs.uk/2014/02/20/psa-spinal-chemo/

 

 Safer spinal (intrathecal), epidural and regional devices - Part A: update - Click here to view
(31 January 2011) - 574 KB

Safer spinal (intrathecal), epidural and regional devices - Part A and Part B: Supporting information - Click here to view Part A & Click here to view Part B
(January 2011) - 240 KB

Safer spinal (intrathecal), epidural and regional devices - Part B - Click here to view
(24 November 2009)- 201 KB 

 

Documents and Communications

NHS Pharmaceutical Aseptic Services Group (June 2013):

 - Guidance on implementation of safer-connecting neuraxial devices in pharmacy aseptic services  - Click here to view

 - Guidance on use of safer-connecting neuraxial devices in pharmacy aseptic services - Click here to view

AAMI / ISO timeline for non-Luer neuraxial connector development (April 2013) - Click here to view

Smiths Medical Non-Luer Position Statement (April 2013) - Click here to view

SUPERCEDED - NHS Pharmaceutical Aseptic Services Group position statement (March 2013) - Click here to view

Neuraxial test programme for Wales (March 2013) - Click here to view

Updated statement (February 2013) AAGBI, RCoA, OAA, RA-UK, APA, FPM-RCoA, RCoA-PLG. - Click here to view

SUPERCEDED - NHS Pharmaceutical Aseptic Services Group position statement (November 2012) - Click here to view

Letter from OAA President (17 February 2012) sent to all members - Click here to view

NPSA Rapid Response Report (28 November 2011) - Click here to view

SUPERCEDED - Response to updated position statement from Professor Brian Toft and Professor David Cousins - Click here to view

SUPERCEDED - Updated position statement (25 October 2011) AAGBI, RCoA, OAA, RA-UK, APA, RCoA-PLG - Click here to view

SUPERCEDED- Response (1 September 2010) from Professor David Cousins - Click here to view

SUPERCEDED - Letter (16 August 2010) to Professor David Cousins (Head of Patient Safety - Medication and Medical Devices, NPSA) from Presidents of AAGBI, OAA, RCoA and APAGBI - Click here to view

Film - "Just Another Day" (World Health Organisation video 'Learning from Error - Click here to view

  

 

Published evaluations

Evaluations of non-Luer spinal equipment:

Cook et al. Anaesthesia 2010; 65:1059. Neurax / B-Link (UK) Ltd / Spinalok/InterVene Ltd - Click here to view

And accompanying editorial Walker et al. Anaesthesia 2010; 65:1059 - Click here to view

Lawton et al. Quality Safety Health Care 2009; 18:492 and also Neurax / B-Link (UK) Ltd / Spinalok/InterVene Ltd - Click here to view

Onia et al. British Journal of Anaesthesia 2012; 108:134 BD UniVia-6 - Click here to view

Kinsella et al. Anaesthesia 2012; 67:1217 Pajunk / Bluebox Polymedic / Sarstedt / Smiths - Click here to view

And accompanying correspondence from Brian Toft and David Cousins Anaesthesia 2013; 68:426 and response Kinsella et al. Anaesthesia 2013; 68-426

Sharpe et al. Anaesthesia 2013; 68:562 - Sarstedt / BD / Pajunk / Neurax / Smiths / Vygon / BBraun - Click here to view

Ahmed et al. International Journal of Obstetric Anesthesia 2013:22:S14 -  BD / Smiths-Portex / Vygon / BBraun / Pajunk

Bhalla et al. International Journal of Obstetric Anesthesia 2013:22:S33 - Flexicare Hall Lock / Pajunk Surety / Transmed Surety / Neurax B-Link / Smiths CorrectInject / BD UniVia

Rao & Singh. Survey on the usage of non-luer spinal needles: departmental experience and opinion. OAA Annual Meeting poster, Bournemouth. 2013.

Howatson et al. AAGBI Annual Scientific Meeting, Dublin, 2013 Sarstedt / BD / Pajunk / / Smiths / BBraun / Vygon

 

Outcomes using non-Luer spinal equipment

Rangarajan & Noblet. International Journal of Anesthesia 2013; 22:S16

Susnerwala et al.  British Journal of Anaesthesia 2013;111:686P