External Ventricular Drain Misadministration Events: Systematic Literature Review and Report of a Case

Area of Science:

• Neurosurgery
• Patient Safety
• Medical Device Standards

Background:

• External ventricular drains (EVDs) are crucial in neurosurgery but carry risks like misplacement and infection.
• A critical, yet less discussed, complication is the misadministration of medications or fluids into the EVD system.
• This review focuses on EVD misadministration and preventative strategies, including new connector standards.

Purpose of the Study:

• To review existing literature on medication misadministration into EVDs.
• To present a case of blood product misadministration into an EVD.
• To discuss contributing factors and recommend safety measures, emphasizing the ISO 80369 standard.

Main Methods:

• Systematic literature review of PubMed, Embase, and SCOPUS databases.
• Case report of blood product misadministration into an EVD.
• Analysis of contributing factors, relevant guidelines, and proposed preventive strategies.

Main Results:

• Identified 8 cases of misadministration involving contrast agents, anesthetics, and antiepileptics.
• Reported the first case of blood transfusion misadministration into an EVD, leading to patient death.
• Contributing factors included system unfamiliarity, connector similarity, and poor visibility.

Conclusions:

• Misadministration into EVD connectors is a preventable patient safety issue.
• Adoption of ISO standard neuraxial connectors (e.g., NRFit®) is recommended to prevent misconnections.
• Enhanced training and distinct equipment marking are vital for minimizing risks.