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An engineered solution to the maladministration of spinal injections.
1Institute of Psychological Sciences, University of Leeds, Leeds LS2 9JT UK. r.j.lawton@leeds.ac.uk
Quality & Safety in Health Care
|December 4, 2009
Summary
Dedicated spinal equipment incompatible with Luer syringes can prevent misconnections during spinal injections. A modified non-Luer system showed improved clinician satisfaction and is progressing to clinical evaluation.
Area of Science:
- Medical device engineering
- Patient safety in healthcare
Background:
- The Department of Health (DH) is addressing spinal injection maladministration.
- Misconnection errors with standard Luer syringes pose a risk in spinal procedures.
Purpose of the Study:
- To implement an engineered solution to prevent spinal injection misconnections.
- To investigate dedicated spinal equipment incompatible with Luer devices.
Main Methods:
- Systematic approach to eradicate misconnection errors.
- Bench-testing of non-Luer connectors.
- Hazard analysis of spinal procedures.
- Usability evaluation of prototype devices.
Main Results:
- Two potential risks identified requiring management for implementation.
- One prototype design deemed inadequate due to a separable adapter.
- A modified second connection system showed improved clinician satisfaction.
Conclusions:
- The second, modified non-Luer connection system was selected for further evaluation.
- The chosen system is undergoing pre-implementation assessment.
- Clinical acceptability of the modified system is currently being evaluated.
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