PSN013/JULY 2015

Managing risks during the transition period to new ISO connectors for medical devices used for enteral feeding and neuraxial procedures

In July 2015, Welsh Government published patient safety notice PSN 013 (downloadable pdf).

The PSN gives some background information on the small bore connector changes as well as requiring Welsh healthcare organisations to undertake specific actions related to the imminent introduction of enteral transition sets.

The first devices to be introduced with the new ISO connectors will be enteral feeding devices. The new ISO 80369-3 enteral connector ( also known as ENFit) will replace the reverse Luer connector which the UK has been using since NPSA alert No 19 (March 2007) recommended the use of reverse Luer for enteral devices (PDF).  A phased implementation will begin in September 2015 in the UK. Initially, only giving sets/extension sets with the new connector will be available. These sets will have the new ENFit female connector on the end, and will include an ENFit to reverse Luer adaptor, to enable users to continue to connect enteral feeds to reverse Luer nasogastric tubes and other enteral feeding/medication devices, which will allow continued use with current designs of enteral feeding tubes and syringes. Together, the sets and adaptors will be known as ‘transition sets’.

In March 2016, we expect the rest of the devices (syringes, feeding tubes, buttons etc) to change to the 80369-3 connector, and there will be little or no requirement for continued use of the adaptors. 

The key actions in the alert are:

  1. Identify if enteral feeding medical devices are being used in your organisation.
  2. Large organisations such as Health Boards and Trusts should set up a multiprofessional local group with appropriate expertise to help manage and communicate the enteral feeding device changeover.
  3. Liaise with smaller organisations such as private nursing homes on this matter. 
  4. If devices affected by the change are being used, ensure that an action plan is in place to minimise the risks during the transition period.  It is expected that this will include making staff and patients aware of the change, provision of training and education, and managing the logistics of the changeover.
  5.  Distribute this Alert to all staff involved in purchasing, training and distribution of affected medical devices.

Actions are to be completed by 13th August 2015.

The Enteral sub group of the WNCRG (Wales Non-Luer Connectors Reference Group) is working to coordinate this change across Wales.

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