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Improving patient safety by design - a new spinal/intrathecal injection safety system

British Columbia’s Children’s Hospital, Vancouver, Canada, E-mail: dblackstock{at}cw.bc.ca

To the Editor:

Giving the wrong drug by the spinal, epidural or iv route can cause serious morbidity or be fatal.^1–3 Such drug injection errors arise in part because Luer tapered fit connectors used for a wide range of medical devices are the same size and can be incorrectly identified and erroneously connected together. Increasing patient safety will require the replacement of existing Luer connectors with incompatible alternatives ^4,5

A multidisciplinary group including the British Columbia Institute of Technology has designed a spinal injection safety system (SISS)© to prevent the inadvertent intrathecal injection of the wrong drug (vincristine) during treatment for leukemia. Medication drawn into the spinal syringe using a special SISS filling device cannot be given using existing needles, as these will not fit together. Conversely, medication put into Luer Lok syringes are not compatible with the SISS spinal needle. If adopted as a spinal drug administration standard by individual institutions and/or safety groups, we believe this forcing function; syringe/needle system will represent a major improvement in the safety of spinal drug administration. The SISS is currently under prototype development having received patent approval in early 2003.

We have started designing a similar safety system for epidural drug administration that should be of particular interest to anesthesiologists as the Canadian Anesthesiologists’ Society Guidelines to the Practice of Anesthesia 2002, recommended, "Until a specific connection system is devised for neuraxial use, both sides of all Luer connections should be labelled".

View larger version (29K): [in this window] [in a new window]   FIGURE shows an engineering image of the spinal injection safety system (SISS) syringe and needle. Section A shows the engineering drawing of the spinal syringe and needle. Section B technical drawings showing incompatibility of the syringe with existing slip tip, Luer LokTM syringes and a conventional needle. Adapted with permission from Can J Hosp Pharma 2004; 57: 176–9.

Accepted for publication September 13, 2005.

References

1 ISMP MedicationSafetyalert. Intrathecal injection of ionic contrast media may be fatal. 2003; 8: 1–2.

2 Sidi A, Froelich MA. Inadvertent epidural injection of ephedrine in labor. J Clin Anesth 2004; 16: 74–6.[Medline]

3 Dernedde M, Furlan D, Verbesselt R, Gepts E, Boogaerts JG. Grand mal convulsion after an accidental intrave-nous injection of ropivacaine. Anesth Analg 2004; 98: 521–3.[Abstract/Free Full Text]

4 Berwick DM. Not again! (Editorial). BMJ 2001; 322: 247–8.[Free Full Text]

5 Reason J. Human error: models and management. BMJ 2000; 320: 768–70.[Free Full Text]

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