Unintentional Infusion of Phenylephrine into the Epidural Space

[NRFit: A new standard to prevent wrong-route medication errors]

Wrong route medication errors due to tubing misconnections can lead to serious adverse events, especially when they concern the neuraxial and perineural routes. It has been favoured by the use of the universal Luer connector for medical devices with a risk of confusion with the intravenous route. The prevention of these errors is based on passive measures such as using specific small-bore connectors, and active measures such as reading Specific labelling which must be systematically affixed to the routes. NRFit connectors are a type of small-bore connector specifically intended for neuraxial and perineural applications. They are based on the International Organization for Standardization (ISO) standard 80369-6. They are physically incompatible with other small-bore connectors, like the Luer connectors used for intra-venous and enteral medication administration, and thus help prevent inadvertent misconnections. While some countries have already implemented this standard, France is behind schedule in implementing the NRFit connectors due to the absence of strong recommendations or obligations from the authorities. However, NRFit connectors represents real progress for the prevention of medication errors.

Neuraxial and peripheral misconnection events leading to wrong-route medication errors: a comprehensive literature review

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.

New solutions to reduce wrong route medication errors

Wrong route medication errors due to tubing misconnections are potentially life-threatening complications that have been made possible by the universal use of the Luer connector. The new International Organization of Standardization standards for small bore connectors, ISO 80369 series, have been developed to reduce the risk of these types of erroneous connections. Tubing connectors for different routes of clinical application will contain differently designed connectors that are physically incompatible. However, design and manufacturing standards have progressed slowly, and clinical roll-outs have been delayed, despite the implementation of California laws to promote their use. We are currently in a state of transition where new connectors for enteral and neuraxial use will be entering the clinical market in the next few years, and increasing use will identify additional patient safety concerns.