The Issue
In the past few years there have been many deaths and paralysis as a result of spinal / epidural medication being administered by the IV route and vice versa.
In its report “An Organisation with a Memory” (2000) the Department of Health outlined certain targets including the implementation of devices with engineered safety features to prevent neuraxial medication errors.
Since the National Patient Safety Agency issued an alert in March 2007 advocating safer use of epidural medicines, healthcare organisations have suggested that recommendations have been implemented. However, between January 2008 and March 2009 the NPSA received 11 patient safety incident reports of wrong route errors with Neuraxial devices and medicines. Five of these reports involved epidural medicine being administered by the intravenous route and six intravenous medication via the epidural route.
Sir Liam Donaldson introduces a video illustrating how a misconnection tragedy might occur. Click above to watch.
© Copyright - InterVene Limited 2011
In January 2009 Professor Brian Toft announced at a Commons Health Committee meeting that in the years following his report into the devastating case of Wayne Jowett who tragically died at QMC in Nottingham in 2001, no medical devices aimed at preventing a recurrence of this tragedy had been commercialised. It was following this press release that InterVene Limited went ‘live’ with its neuraxial project under the development name "Spinalok®" (Spinal-OK) and began developing the Surety® system that is available today. In July 2010, the brand name was changed so as to also enable the system to be used for epidurals and regional anaesthesia.
