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UK hospitals ordered to cut risk of drugs going wrongly into spinal fluid

BMJ 2009; 339 doi: https://doi.org/10.1136/bmj.b5076 (Published 27 November 2009) Cite this as: BMJ 2009;339:b5076

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  1. Jane Feinmann
  1. 1London

    A new safety initiative is being launched in England and Wales to try to make it impossible for staff to inject medicines designed for intravenous use into the spinal fluid.

    The Department of Health is going to require NHS trusts across England and Wales to eliminate the use of “universal” connectors to administer medicines into the spinal fluid. They are being asked to ensure that all spinal (intrathecal) bolus doses and lumbar puncture samples are only performed using syringes, needles, and other devices with connectors that will not also connect to intravenous luer connectors. The deadline for compliance with this Patient Safety Alert is April 2011.

    The guidelines see the belated implementation of the Department of Health’s 2001 inquiry into the death of Wayne Jowett, the 18 year old leukaemia patient who died earlier that year when the anti-cancer drug, vincristine, was mistakenly …

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