The National Patient Safety Agency (NPSA) has issued a “Rapid Response Report (RRR)” on minimising the risks of mismatching spinal, epidural and regional devices with incompatible connectors following the report of an 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.

In response to an NPSA alert issued in 2009, 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. This RRR provides additional guidance to the alert, and makes the following recommendations, to be implemented by 31 March 2012:

• Alert healthcare staff who order, receive, transport, restock and clinically use spinal, epidural and regional devices of the risk of mis-matching connectors.

• Check current stocks of spinal, epidural and regional devices to ensure these devices are compatible.

• Amend written distribution and clinical procedures to confirm the identity of the connectors used in devices. Checks should not solely rely on catalogue code numbers. The term ‘Luer’ and where neuraxial connectors are fitted, the device trademark should be used to identify different connector designs. Currently Correctinject®, Hall Lock®, Neurax®, Surety®, UniVia® are trademarks being used. Only devices with the same connector descriptors are compatible. In addition, other design elements such as colour, text and symbols should assist users to identify the type of connector used in the device.

• Use procedure packs where feasible and appropriate to ensure that all the devices required for a specified procedure are compatible and readily available.

• Recommend clinical staff check all devices required for a procedure are fitted with the same connector design before commencing the procedure.