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[NRFit:预防用药错误路径错误的新标准]

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

作者信息

Vacheron C-H, Piriou V, Untereiner O, Picard J, Thiveaud D, Theissen A

机构信息

Département d'anesthésie réanimation, Hospice Civil de Lyon, Centre Hospitalier Lyon-Sud, Lyon, France; Hospices civils de Lyon, Pôle santé publique, service de biostatistique-Bioinformatique, Lyon, France; Université Claude Bernard Lyon 1, Faculté de Médecine, Lyon, France; Comité analyse et maîtrise du Risque, SFAR, Paris, France.

Département d'anesthésie réanimation, Hospice Civil de Lyon, Centre Hospitalier Lyon-Sud, Lyon, France; Université Claude-Bernard Lyon 1, faculté de médecine, Lyon, France.

出版信息

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

DOI:10.1016/j.pharma.2022.03.002
PMID:35490701
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.

摘要

因管路误连导致的用药途径错误会引发严重不良事件,尤其是涉及神经轴和神经周围途径时。医疗设备使用通用鲁尔接头,存在与静脉途径混淆的风险,这使得此类错误更易发生。预防这些错误基于被动措施,如使用特定的小口径接头,以及主动措施,如阅读必须系统贴于各途径上的特定标签。NRFit接头是一种专门用于神经轴和神经周围应用的小口径接头。它们基于国际标准化组织(ISO)标准80369-6。它们在物理上与其他小口径接头不兼容,如用于静脉和肠内给药的鲁尔接头,从而有助于防止意外误连。虽然一些国家已经实施了该标准,但由于当局缺乏有力的建议或规定,法国在实施NRFit接头方面落后于计划。然而,NRFit接头在预防用药错误方面代表了真正的进步。

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