Hi Everyone,

You receive a phone call at 2am from a junior colleague who tells you that they are managing a code blue caesarean section and in the confusion of urgently administering a number of different medications they have just accidentally injected 10ml of cephazolin into the epidural catheter instead of the intravenous tubing. They are understandably upset and worried. (* This is a hypothetical scenario).

What are wrong route errors? How common are they? How do they happen?

Article from 2012 - "The US Pharmacopeia, the largest information source of tube misconnection related errors, has received 1600 reports of epidural to central or peripheral intravenous misconnections since 1999."

What is NRFIT and how will this help improve patient safety? When is it coming? - It is already here and will probably coming to your health service soon. Many hospitals around the world including all of Japan have already changed over and a few sites in Australia / NZ have also now introduced NRFIT.

Join Graeme and I as we discuss the issue of wrong route errors, and what you need to know about NRFIT, as well of course a few bad Xmas jokes!

LINKS

Reducing Risk of Epidural-Intravenous Misconnections - APSF Newsletter Winter 2012

Challenges when introducing NRFit™ at a tertiary hospital in Japan International Journal of Obstetric Anesthesia, 2022-02-01, Volume 49, Article 103244 . This article is behind Elseviers firewall but you should be able to access it through the ANZCA library or your own hospitals if you are lucky enough to have these available.

NRFIT Pajunk

Stay connected GEDSA NRFIT website