[NRFit: A new standard to prevent wrong-route medication errors]

Ann Pharm Fr. 2023 Jan;81(1):30-39. doi: 10.1016/j.pharma.2022.03.002. Epub 2022 Apr 28.
[Article in French]

Abstract

Wrong route medication errors due to tubing misconnections can lead to serious adverse events, especially when they concern the neuraxial and perineural routes. It has been favoured by the use of the universal Luer connector for medical devices with a risk of confusion with the intravenous route. The prevention of these errors is based on passive measures such as using specific small-bore connectors, and active measures such as reading Specific labelling which must be systematically affixed to the routes. NRFit connectors are a type of small-bore connector specifically intended for neuraxial and perineural applications. They are based on the International Organization for Standardization (ISO) standard 80369-6. They are physically incompatible with other small-bore connectors, like the Luer connectors used for intra-venous and enteral medication administration, and thus help prevent inadvertent misconnections. While some countries have already implemented this standard, France is behind schedule in implementing the NRFit connectors due to the absence of strong recommendations or obligations from the authorities. However, NRFit connectors represents real progress for the prevention of medication errors.

Keywords: Anesthésie loco-régionale; Connecteurs de petit calibre; ISO 83069 standard; NRFit system; Norme ISO 83069; Patient safety; Regional block procedures; Small-bore connectors; Système NRFit; Sécurité du patient.

Publication types

  • English Abstract
  • Review

MeSH terms

  • Equipment Design
  • Humans
  • Infusions, Intravenous
  • Medication Errors* / prevention & control
  • Pharmaceutical Preparations
  • Reference Standards

Substances

  • Pharmaceutical Preparations