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Ishida Y, Homma Y, Kawamura T, Sagawa M, Toba Y. Accidental epidural catheter removal rates and strength required for disconnection: a retrospective cohort and laboratory study. BMC Anesthesiol 2022; 22:185. [PMID: 35710348 PMCID: PMC9200947 DOI: 10.1186/s12871-022-01728-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 06/10/2022] [Indexed: 11/21/2022] Open
Abstract
Background Epidural catheters are associated with certain risks such as accidental epidural catheter removal, including dislodgement and disconnection. Globally, neuraxial connector designs were revised in 2016 to provide new standardization aimed at decreasing the frequency of misconnections during the administration of medications. However, no studies have investigated accidental epidural catheter removal after the revised standardization. This study aimed to examine differences in dislodgement and disconnection rates associated with different catheter connector types, and to investigate the linear tensile strength required to induce disconnection. Methods This retrospective cohort study included adult patients who underwent elective surgery and received patient-controlled epidural analgesia. Patients were divided into groups according to the type of catheter connection used: old standard, new standard, and new standard with taping groups. Furthermore, we prepared 60 sets of epidural catheters and connectors comprising 20 sets for each of the old, new, and taping groups, and used a digital tension meter to measure the maximum tensile strength required to induce disconnection. Results This clinical study involved 360, 182, and 378 patients in the old, new, and taping groups, respectively. Dislodgement rates did not differ statistically among the three groups, while there was a significant difference in disconnection rates. Propensity score matching analysis for disconnection rates showed no difference between the old and new groups (2.8% vs. 4.5%, p = 0.574), while the new group had higher rates than the taping group (6.5% vs. 0%, p = 0.002). This laboratory study identified that a tensile strength of 12.41 N, 12.06 N, and 19.65 N was required for disconnection in the old, new, and taping groups, respectively, and revealed no significant difference between the new and old groups (p = 0.823), but indicated a significant difference between the new and taping groups (p < 0.001). Conclusions This clinical study suggested that dislodgement rates did not change among the three groups. Both clinical and laboratory studies revealed that disconnection rates did not change between the old and new connectors. Moreover, as a strategy to prevent accidents, taping the connecting points of the catheter connectors led to an increase in the tensile strength required for disconnection. Supplementary Information The online version contains supplementary material available at 10.1186/s12871-022-01728-z.
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Affiliation(s)
- Yoshiaki Ishida
- Department of Anesthesiology, Seirei Hamamatsu General Hospital, 2-12-12 Sumiyoshi, Naka-ku, Hamamatsu-shi, Shizuoka, 430-8558, Japan.
| | - Yoichiro Homma
- Department of General Internal Medicine, Seirei Hamamatsu General Hospital, Hamamatsu, Japan
| | - Takashi Kawamura
- Department of Clinical Engineering, Seirei Hamamatsu General Hospital, Hamamatsu, Japan
| | - Masatoshi Sagawa
- Department of Clinical Engineering, Seirei Hamamatsu General Hospital, Hamamatsu, Japan
| | - Yoshie Toba
- Department of Anesthesiology, Seirei Hamamatsu General Hospital, 2-12-12 Sumiyoshi, Naka-ku, Hamamatsu-shi, Shizuoka, 430-8558, Japan
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Viscusi ER, Hugo V, Hoerauf K, Southwick FS. Neuraxial and peripheral misconnection events leading to wrong-route medication errors: a comprehensive literature review. Reg Anesth Pain Med 2020; 46:176-181. [PMID: 33144409 PMCID: PMC7841481 DOI: 10.1136/rapm-2020-101836] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 09/24/2020] [Accepted: 09/29/2020] [Indexed: 11/03/2022]
Abstract
We conducted a search of the literature to identify case reports of neuraxial and peripheral nervous system misconnection events leading to wrong-route medication errors. This narrative review covers a 20-year period (1999-2019; English-language publications and abstracts) and included the published medical literature (PubMed and Embase) and public access documents. Seventy-two documents representing 133 case studies and 42 unique drugs were determined relevant. The most commonly reported event involved administering an epidural medication by an intravenous line (29.2% of events); a similar proportion of events (27.7%) involved administering an intravenous medication by an epidural line. Medication intended for intravenous administration, but delivered intrathecally, accounted for 25.4% of events. In the most serious cases, outcomes were directly related to the toxicity of the drug that was unintentionally administered. Patient deaths were reported due to the erroneous administration of chemotherapies (n=16), muscle relaxants (n=4), local anesthetics (n=4), opioids (n=1), and antifibrinolytics (n=1). Severe outcomes, including paraplegia, paraparesis, spinal cord injury, and seizures were reported with the following medications: vincristine, gadolinium, diatrizoate meglumine, doxorubicin, mercurochrome, paracetamol, and potassium chloride. These case reports confirm that misconnection events leading to wrong-route errors can occur and may cause serious injury. This comprehensive characterization of events was conducted to better inform clinicians and policymakers, and to describe an emergent strategy designed to mitigate patient risk.
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Affiliation(s)
- Eugene R Viscusi
- Department of Anesthesiology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Vincent Hugo
- Becton, Dickinson and Company, Franklin Lakes, New Jersey, USA
| | - Klaus Hoerauf
- Becton, Dickinson and Company, Franklin Lakes, New Jersey, USA.,Department of Anesthesiology and Intensive Care Medicine, Medical University of Vienna, Wien, Austria
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Palanisamy A, Kinsella SM. Spinal tranexamic acid - a new killer in town. Anaesthesia 2019; 74:831-833. [PMID: 30985919 DOI: 10.1111/anae.14632] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/10/2019] [Indexed: 11/27/2022]
Affiliation(s)
- A Palanisamy
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA
| | - S M Kinsella
- Department of Anaesthesia, St Michael's Hospital, Bristol, UK
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Cook TM, Wilkes A, Bickford Smith P, Dorn L, Stacey M, Kinsella SM, Sharpe P, Phillips P. Multicentre clinical simulation evaluation of the
ISO
80369‐6 neuraxial non‐Luer connector. Anaesthesia 2019; 74:619-629. [DOI: 10.1111/anae.14585] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/27/2018] [Indexed: 11/28/2022]
Affiliation(s)
- T. M. Cook
- Department of Anaesthesia and Intensive Care Medicine Royal United Hospitals Bath NHS Foundation Trust BathUK
- School of Medicine University of Bristol Bristol UK
| | - A. Wilkes
- Independent Medical Device Consultant Edinburgh UK
| | | | - L. Dorn
- Associate Director Clinical Development Baxter Healthcare Chicago IllinoisUSA
| | - M. Stacey
- Cardiff & Vale University Hospitals Board Cardiff UK
| | - S. M. Kinsella
- University Hospitals Bristol NHS Foundation Trust BristolUK
| | - P. Sharpe
- University Hospitals of Leicester NHS Trust LeicesterUK
| | - P. Phillips
- Surgical Materials Testing Laboratory Princess of Wales Hospital Bridgend UK
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Cross-sectional study of perioperative drug and allergen exposure in UK practice in 2016: the 6th National Audit Project (NAP6) Allergen Survey. Br J Anaesth 2018; 121:146-158. [DOI: 10.1016/j.bja.2018.04.016] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Revised: 04/01/2018] [Accepted: 04/16/2018] [Indexed: 12/20/2022] Open
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Mahmood A, Sharpe P. Non-Luer butterfly needle with one-way valve for epidural blood patch: impact on blood clotting. Anaesthesia 2018; 73:911-912. [PMID: 29890000 DOI: 10.1111/anae.14334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- A Mahmood
- University Hospitals of Leicester, Leicester, UK
| | - P Sharpe
- University Hospitals of Leicester, Leicester, UK
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Pillai A, Monteiro RS, Choi SW, Yentis SM, Bogod D. Strength of commonly used spinal needles: the ability to deform and resist deformation. Anaesthesia 2017; 72:1125-1133. [PMID: 28696015 DOI: 10.1111/anae.13959] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/09/2017] [Indexed: 11/29/2022]
Abstract
We investigated the strength of commonly used spinal needles in relation to the amount of deformation, and registered forces during standardised testing. We investigated differences between manufacturers for the same length and gauge of Luer and non-Luer needles, and examined the effect of the internal stylet in terms of needle strength. A specialised rig was designed to perform the testing in both the horizontal and axial plane, reflecting common industrial tests and clinical use. Needles from four commonly used manufacturers were used (Vygon, Becton Dickinson, B Braun, and Pajunk). Needles of 25 G and 27 G were tested in 90-mm and 120-mm lengths. We found significant differences in terms of the size of final deformation and 'toughness'/resistance to deformation between needles of different brands. There were also significant differences between horizontal tests conducted as an industry standard and our own axial test. This may have bearing on clinical use in terms of the incidence of bending and breakage. The presence of the internal stylet resulted in significantly greater toughness in many needles, but had little effect on the degree of deformation. Comparison of Luer and non-Luer needles of the same brand and size showed few significant differences in strength. This result is reassuring, given the imminent change from Luer to non-Luer needles that is to occur in the UK.
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Affiliation(s)
- A Pillai
- Department of Anaesthesia, Nottingham University Hospitals, Nottingham, UK
| | - R S Monteiro
- Department of Anaesthesia, Brighton and Sussex University Hospitals, Brighton, UK
| | - S W Choi
- Laboratory and Clinical Research Institute for Pain, Department of Anaesthesiology, The University of Hong Kong, China
| | - S M Yentis
- Magill Department of Anaesthesia, Chelsea and Westminster Hospital, London, UK
| | - D Bogod
- Department of Anaesthesia, Nottingham University Hospitals, Nottingham, UK
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Monteiro RS, Pillai A, Choi SW, Bogod D, Yentis SM. Flow characteristics of Luer and non-Luer spinal needles. Anaesthesia 2017; 72:749-754. [DOI: 10.1111/anae.13851] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/26/2017] [Indexed: 11/28/2022]
Affiliation(s)
- R. S. Monteiro
- Department of Anaesthesia; Chelsea and Westminster Hospital; London UK
| | - A. Pillai
- Department of Anaesthesia; Nottingham University Hospitals; Nottingham UK
| | - S. W. Choi
- Laboratory and Clinical Research Institute for Pain; Department of Anaesthesiology; The University of Hong Kong; Hong Kong China
| | - D. Bogod
- Department of Anaesthesia; Nottingham University Hospitals; Nottingham UK
| | - S. M. Yentis
- Department of Anaesthesia; Chelsea and Westminster Hospital; London UK
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Vincent CJ, Blandford A. How do health service professionals consider human factors when purchasing interactive medical devices? A qualitative interview study. APPLIED ERGONOMICS 2017; 59:114-122. [PMID: 27890119 DOI: 10.1016/j.apergo.2016.08.025] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/30/2016] [Revised: 08/23/2016] [Accepted: 08/26/2016] [Indexed: 06/06/2023]
Abstract
We present findings of a UK study into how those involved in purchasing interactive medical devices go about evaluating usability, the challenges that arise, and opportunities for improvement. The study focused on procurement of infusion devices because these are used by various professionals across healthcare. A semi-structured interview study was carried out involving a range of stakeholders (20 in total) involved in or impacted by medical device procurement. Data was analysed using thematic analysis, a qualitative method designed to support the identification, analysis and reporting of patterns. In principle, health service purchasing was found to accommodate consideration of equipment usability. In practice, the evaluation process was driven primarily by engineering standards; assessment of local needs did not accommodate substantive assessment of usability; and choice was limited by the availability of equipment on the marketplace. We discuss ways in which purchasing could be improved through techniques that account for social circumstances.
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Affiliation(s)
| | - Ann Blandford
- UCLIC, 66-72 Gower Street, University College London, London, WC1E 6BT, UK.
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Lamont T, Waring J. Safety lessons: shifting paradigms and new directions for patient safety research. J Health Serv Res Policy 2016; 20:1-8. [PMID: 25472984 DOI: 10.1177/1355819614558340] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Tara Lamont
- NIHR Health Services & Delivery Research Programme, University of Southampton, 3 Venture Road, Science Park, Southampton SO16 7NS, UK
| | - Justin Waring
- Nottingham University Business School, University of Nottingham, UK
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Agámez GL, Arnal D. [Towards a No-Luer connection for neuraxial procedures: slow and safe]. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2014; 61:121-124. [PMID: 24199912 DOI: 10.1016/j.redar.2013.09.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/10/2013] [Accepted: 09/20/2013] [Indexed: 06/02/2023]
Affiliation(s)
- G L Agámez
- Unidad de Anestesia y Reanimación, Hospital Universitario Fundación Alcorcón, Alcorcón, Madrid, España
| | - D Arnal
- Unidad de Anestesia y Reanimación, Hospital Universitario Fundación Alcorcón, Alcorcón, Madrid, España; Sistema Español de Notificación en Seguridad en Anestesia y Reanimación (SENSAR), Madrid, España.
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Russell R, Lucas N. Obstetric anaesthesia guidelines. Int J Obstet Anesth 2014; 23:101-5. [PMID: 24507474 DOI: 10.1016/j.ijoa.2013.10.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2013] [Accepted: 10/29/2013] [Indexed: 11/29/2022]
Affiliation(s)
- Robin Russell
- Nuffield Department of Anaesthetics John Radcliffe Hospital, Oxford, UK.
| | - Nuala Lucas
- Department of Anaesthetics Northwick Park Hospital, Harrow, UK
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Dias J, Lages N, Marinho A, Maria L, Tinoco J, Vieira D, Correia C. Accidental spinal potassium chloride injection successfully treated with spinal lavage. Anaesthesia 2013; 69:72-6. [DOI: 10.1111/anae.12486] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/20/2013] [Indexed: 10/26/2022]
Affiliation(s)
- J. Dias
- Anaesthesia Service; Centro Hospitalar Do Alto Ave; Guimarães Portugal
| | - N. Lages
- Anaesthesia Service; Centro Hospitalar Do Alto Ave; Guimarães Portugal
| | - A. Marinho
- Anaesthesia Service; Centro Hospitalar Do Alto Ave; Guimarães Portugal
| | - L. Maria
- Anaesthesia Service; Centro Hospitalar Do Alto Ave; Guimarães Portugal
| | - J. Tinoco
- Anaesthesia Service; Centro Hospitalar Do Alto Ave; Guimarães Portugal
| | - D. Vieira
- Anaesthesia Service; Centro Hospitalar Do Alto Ave; Guimarães Portugal
| | - C. Correia
- Anaesthesia Service; Centro Hospitalar Do Alto Ave; Guimarães Portugal
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Kinsella SM. Luers, ethics, research and service evaluation: more than just the sharp end. Anaesthesia 2013; 68:555-7. [DOI: 10.1111/anae.12264] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- S. M. Kinsella
- St Michael's Hospital; University Hospitals Bristol NHS Foundation Trust; Bristol; UK
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Sharpe P, Scott S, Gross JM. An evaluation of non-Luer safety connectors for neuraxial procedures. Anaesthesia 2013; 68:562-70. [DOI: 10.1111/anae.12228] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/21/2013] [Indexed: 11/27/2022]
Affiliation(s)
- P. Sharpe
- University Hospitals of Leicester NHS Trust; Leicester; UK
| | - S. Scott
- East Midlands (South) School of Anaesthesia; Leicester; UK
| | - J. M. Gross
- University Hospitals of Leicester NHS Trust; Leicester; UK
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Cook TM. Luers, ethics, research and service evaluation: even more shades of grey? Anaesthesia 2013; 68:551-4. [DOI: 10.1111/anae.12263] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- T. M. Cook
- Anaesthesia and Intensive Care; Royal United Hospital; Bath; UK
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Kinsella S. The shock of the ‘Nuer’: the UK experience with new non-Luer neuraxial equipment and implications for obstetric anaesthesia. Int J Obstet Anesth 2013; 22:1-5. [DOI: 10.1016/j.ijoa.2012.09.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2012] [Accepted: 09/17/2012] [Indexed: 10/27/2022]
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Cook TM, Pandit JP, Wilkes AR. Introduction and evaluation of new airway devices: Current issues. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2012. [DOI: 10.1016/j.tacc.2012.08.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Kinsella SM, Goswami A, Laxton C, Kirkham L, Wharton N, Bowen M. A clinical evaluation of four non-Luer spinal needle and syringe systems. Anaesthesia 2012; 67:1217-24. [DOI: 10.1111/j.1365-2044.2012.07297.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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