The HSE has begun implementing NRFit connectors and devices in all public hospitals to reduce the risk of wrong route administration of medication, the Medical Independent understands.
Four public hospitals have transitioned to using NRFit connectors and compatible devices. At least two other hospitals are in the process of transitioning. A similar process has been ongoing within the NHS in recent years.
Between 2018 and 2024, some 20 incidents were reported where a drug was “connected to the wrong access”, according to the HSE. This data is based on a search of anaesthesiology-related incidents recorded on the national incident management system.
“Fortunately, none of these have led to serious harm. Seven incidents may have been prevented with NRFit connectors,” said a HSE spokesperson.
For many years, hospitals have used a range of medical devices with the universal Luer connector to administer medicines via different routes of administration, including the intravenous, intrathecal, and epidural routes.
The commonality of connector carries significant risk of accidental wrong route administration of medication. This could result in a fatal outcome, particularly if medication intended to be administered via a vein is wrongly injected into the spine.
NRFit connectors are used for connecting medical devices involved in neuraxial and regional anaesthesia procedures. NRFit devices are not compatible with Luer connectors, which reduces the risk of medication being delivered by the wrong route.
Asked about the challenges of this transition, the HSE spokesperson said: “Supply and cost is dictated by manufacturer production scales. The biggest challenge in transitioning is the supply of NRFit equipment. We are now mitigating this risk by ensuring that there are multiple companies (four at present) that are able to reliably supply NRFit equipment to the HSE hospitals.”
They added: “The HSE, with the College of Anaesthesiologists, will also provide educational support in how to transition with experience learnt from HSE hospitals already transitioned and also from Northern Ireland and the UK.”
Currently, the implementation of NRFit devices is not mandatory. Some hospitals may have challenges in transitioning or the process may pose greater risk than benefit.
“As we are in the early stages of scoping out this transition, dependent on external factors such as equipment availability and guaranteed supply, the timeline for completion is not certain at present.”
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