Safeguarding patient safety and reducing misconnection errors (9 July 2024)

Summary

“Wrong route” medication errors can have catastrophic consequences, including paraparesis, paraplegia or death. These types of errors usually occur as the result of misconnections, where medication is administered using the wrong route, such as administering an epidural medication by an intravenous line, administering an intravenous medication by an epidural line or delivering medication intended for intravenous administration intrathecally (into the fluid surrounding the spinal cord). This article by the pharmaceutical company BD looks at how the universal male-female configuration of Luer connectors, which are widely used across the NHS, contributes to wrong route medication errors. It describes the prevalence of these errors and outlines why NHS England is transitioning to using an alternative system for all intrathecal and epidural procedures and delivery of regional blocks.