Since the untimely death of Wayne Jowett in 2001, who died after a toxic cancer drug was wrongly injected into his spine at Nottingham's Queen's Medical Centre, the NHS, medical device industry and various global standards organisations have been trying to produce a mechanical barrier to prevent further tragedies, after the Toft report in 2001 recommended "A new spinal needle with a connection that cannot fit Luer mount intravenous syringes should be introduced, in conjunction with a new syringe which can only be fitted to that specific spinal needle."  In the intervening years various attempts have been made to produce a design which is accepted internationally and which would mitigate these 'wrong route' risks.  

9 years ago, Welsh Government set up a group (the Welsh Non-Luer Connectors Reference Group - WNCRG) which was responsible for monitoring developments in this area and for coordinating the introduction of such devices when they were available.  An international standard was published 2 years ago specifically for epidural and neuraxial devices (ISO 80369-6) which specified new connectors for syringes and needles which would reduce the risks of further wrong-route incidents. Since the publication of that standard, industry have adopted it and have been working with the NHS to deliver medical devices incorporating the new connector.

A decision was made in mid 2017 that Aneurin Bevan University Health Board would be the first Welsh organisation to roll out the new devices.  Doctors Stephen Edwards (Deputy Medical Director - Secondary Care,  ABUHB) and  Paul Nichols (Consultant Anaesthetist, ABUHB)  have since been working with colleagues in Welsh Procurement, WNCRG and their own health board to ensure a smooth transition, and finally in mid January 2018, NRFit compatible medical devices were deployed in ABUHB.  

At the date of writing (26th Feb 2018) 3 hospitals have made the transition including the Royal Gwent Hospital in Newport.  Other hospitals in Wales will start changing over to the new devices later this year, but completion of the process will not be possible until all of the epidural administration sets are available in NRFit designs. This could mean some hospitals or procedures may have to wait until  Spring 2019 before all the equipment they need is available.


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