Non-Luer connectors: Are we nearly there yet?

Anaesthesia

Volumn 67, Issue 7, 2012, Pages 784-792

  Cook, T M ^a  

^a ROYAL UNITED HOSPITAL   (United Kingdom)

Author keywords

[No Author keywords available]

Indexed keywords

ANESTHESIST; DEVICES; FUNDING; HEALTH CARE ORGANIZATION; HUMAN; LUER CONNECTOR; MARKETING; MEDICAL ERROR; NEUROLOGIST; PEDIATRICIAN; PHYSICIAN; REGIONAL ANESTHESIA; REVIEW; STANDARDIZATION;

ANESTHESIA, CONDUCTION; EQUIPMENT DESIGN; HEALTH CARE SECTOR; HUMANS; MEDICAL ERRORS; PATIENT SAFETY; TECHNOLOGY ASSESSMENT, BIOMEDICAL;

EID: 84862170187     PISSN: 00032409     EISSN: 13652044     Source Type: Journal    
DOI: 10.1111/j.1365-2044.2012.07154.x     Document Type: Review

References (36)

1. National Patient Safety Agency Patient Safety Alert. Safer spinal, epidural and regional anaesthesia devices - Part A. October 2009. http://www.nrls.npsa.nhs.uk/resources/patient-safetytopics/medical-device- equipment/?entryid45=94529 (accessed 20/02/2012).
2. Cook TM, Counsell D, Wildsmith JAW. Major complications of central neuraxial block: report on the 3rd National Audit Project of the Royal College of Anaesthetists. British Journal of Anaesthesia 2009; 102: 179-90 (http://www.rcoa.ac.uk/index.asp?PageID=717 Full report (accessed 20/02/2012).
3. War Hero, 90, in hospital for routine knee operation died after nurse made fatal drugs blunder. Daily Mail On line 4 June 2008. http://www.dailymail. co.uk/news/article-1024131/War-hero-90-hospital-routine-knee-operation-died- nurse-gave-WRONGdrug.html (accessed 20/02/2012).
4. Patient Safety Alerts NPSA/2009/PSA004A and NPSA/2009/PSA004B. Safer spinal (intrathecal), epidural and regional devices - Part A and Part B Supporting information http://www.nrls.npsa.nhs.uk/resources/patient-safety- topics/medicaldevice-equipment/?entryid45=94529 (accessed 20/02/2012).
5. Donaldson L. HSC 2008/001: Updated national guidance on the safe administration of intrathecal chemotherapy http://www.dh.gov.uk/en/ Publicationsandstatistics/Lettersandcirculars/Healthservicecirculars/DH-086870 (accessed 20/02/2012).
6. Department of Health. An Organisation With A Memory. London, DH: Department of Health Expert Group, 2000. http://www.dh.gov.uk/en/ Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH-4065083 (accessed 20/02/2012).
7. The 'never events' list for 2011/12. Department of Health, February 2011, Crown copyright. http://www.dh.gov.uk/en/Publicationsandstatistics/ Publications/PublicationsPolicyAnd-Guidance/DH-124552 (accessed 20/02/2012).
8. Recommendations to prevent administration errors with Velcade (bortezomib). EMA/34910/2012. European Medicines Agency. http://www.ema.europa. eu/docs/en-GB/document-library/Medicine-QA/2012/01/WC500120701.pdf (accessed 29/02/2012).
9. Toft B. External Inquiry into the adverse incident that occurred at Queen's Medical Centre, Nottingham, 4 January 2001. London, DH. 2001. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/ PublicationsPolicyAndGuidance/DH-4010064 (accessed 20/02/2012).
10. National Patient Safety Agency. Risk assessment of spinal procedures with current safeguards and with proposed new connector design options for the Department of Health. NPSA, 2004. http://www.nrls.npsa.nhs.uk/resources/patient- safetytopics/medical-device-equipment (accessed 20/02/2012).
11. NHS Purchasing and Supplies Agency. Pre-marketing assessment of non-Luer connectors for use in the administration of spinal injections. NHS Purchasing and Supply Agency Centre for Evidence-Based Purchasing CEP 07013. 2007.
12. House of Commons Health Committee. Patient Safety. Sixth Report of Session 2008-09, vol 1 Report and formal minutes. June 2009. The Stationary Office. http://www.publications.parliament.uk/pa/cm200809/cmselect/cmhealth/151/ 151i.pdf (accessed 20/02/2012).
13. National Patient Safety Agency. Patient Safety Alert Safer spinal, epidural and regional anaesthesia devices - Part B. October 2009. http://www.nrls.npsa.nhs.uk/resources/patient-safetytopics/medical-device- equipment/?entryid45=94529 (accessed 20/02/2012).
14. The introduction of new neuraxial connectors into the NHS. A Position Statement from: The Association of Anaesthetists of Great Britain and Ireland, The Royal College of Anaesthetists, The Obstetric Anaesthetists' Association, Regional Anaesthesia UK, The Association of Paediatric Anaesthetists of Great Britain and Ireland, Royal College of Anaesthetists Patient Liaison Group. Updated 25th October 2011. http://www.aagbi.org/sites/default/files/ Neuraxial%20position%20statement.pdf (accessed 20/02/2012).
15. Senate Bill No 158, Chapter 294. Senate of California, United States of America. September 2008. http://www.cdph.ca.gov/services/boards/Documents/ SB158chaptered09-25-08.pdf (accessed 20/02/2012).
16. The Government Response to the Health Select Committee Report 'Patient Safety'. October 2009. The Stationary Office. http://www.official-documents.gov. uk/document/cm77/7709/7709.pdf (accessed 20/02/2012).
17. Cook TM, Bland L, Mihai R, Scott S. Litigation related to anaesthesia: an analysis of claims against the NHS in England 1995-2007. Anaesthesia 2009; 64: 706-18.
18. Szypula K, Bogod D, Ashpole K, et al. Litigation associated with regional anaesthesia: an analysis of claims against the NHS in England 1995-2007. Anaesthesia 2010; 65: 443-52.
19. Minimising Risks of Mismatching Spinal, Epidural and Regional Devices with Incompatible Connectors. NPSA/2011/RRR003. 28 November 2011. http://www.nrls.npsa.nhs.uk/resources/?EntryId45=132897 (accessed 20 / 02 / 2012).
20. Joint letter to the NPSA from the Presidents of The Association of Anaesthetists of Great Britain and Ireland, The Royal College of Anaesthetists, The Obstetric Anaesthetists' Association and The Association of Paediatric Anaesthetists of Great Britain and Ireland. August 2010. http://www.aagbi.org/ news/latestnews/2011-news-archive (accessed 20/02/2012).
21. Safer spinal (intrathecal), epidural and regional devices - Alert NPSA/2009/PSA004A http://www.nrls.npsa.nhs.uk/resources/?EntryId45=94529 (accessed 20/02/2012).
22. Safer spinal (intrathecal), epidural and regional devices - Part A update http://www.nrls.npsa.nhs.uk/resources/?EntryId45=94529 (accessed 20/02/2012).
23. Toft B, cousins D. A Response To The Joint Statement On The Implementation Of Neuraxial Devices With Safer Connectors From The Anaesthetic Organisation's Presidents http://www.nrls.npsa.nhs.uk/resources/patient-safety- topics/medicaldevice-equipment/?entryid45=94529 (accessed 20 / 02 / 2012).
24. Neuraxial Update Newsletters'. http://www.nrls.npsa.nhs.uk/resources/? EntryId45=94529 (accessed 20 / 02 / 2012).
25. Cook TM, Payne S, Skryabina E, Hurford D, Clow E, Georgiou A. Safer neuraxial connectors. A simulation-based evaluation of two proposed alternatives to Luer devices for use in neuraxial anaesthesia. Anaesthesia 2010; 65: 1069-79.
26. Onia R, Wu Y, Parvu V, Eshun-Wilson I, Kassler-Taub K. Simulated evaluation of a non-Luer safety connector system for use in neuraxial procedures. British Journal of Anaesthesia. 2012; 108: 134-9.
27. Dyer C, Bryan G. Devices designed to avoid wrong-route administration of drugs. Anaesthesia. 2011; 66: 1181-2.
28. Neuraxial test programme for Wales - 2011 http://smtl.co.uk/nhs-services/ 58-nhs-device-testing/157-neuraxial-non-luer (accessed 20/02/2012).
29. Flow Diagram - Welsh NHS Neuraxial Evaluation Programme (Preliminary). September 2011 http://smtl.co.uk/images/NeuraxialFlow.pdf (accessed 20/02/2012).
30. Spinal/CSE anaesthesia for Caesarean sections using Luer spinal equipment. NOAD/NPSA data as of 12/01/12. http://www.oaa-anaes.ac.uk/assets/- managed/editor/File/NPSA/NOAD-data.pdf (accessed 20/02/2012).
31. Kinsella M. NPSA Patient Safety Alert/PSA/2011/001 Safer spinal needles. Evaluation and incident reporting via OAA/SALG. Anaesthesia News 2011; 287: 19. http://www.aagbi.org/sites/default/files/June-1.pdf (accessed 20/02/2012).
32. Cook TM. Spoilt for choice? New supraglottic airways. Anaesthesia 2003; 58: 107-10.
33. Wilkes AR, Hodzovic I, Latto IP. Introducing new anaesthetic equipment into clinical practice. Anaesthesia. 2008; 63: 571-5. (Pubitemid 351677351)
34. Bickford-Smith PJ. CE marking - caveat emptor? Care of the Critically Ill 1997; 13: 84-5.
35. Pandit JJ, Popat MT, Cook TM, et al. The Difficult Airway Society 'ADEPT' guidance on selecting airway devices: the basis of a strategy for equipment evaluation.Anaesthesia 2011; 66: 726-37.
36. Centre for Evidence-Based Medicine. Levels of Evidence: March 2009. http://www.cebm.net/index.aspx?o =1025 (accessed 20/02/2012).