Building safety into medical devices: The non-injectable arterial connector preventing wrong route drug administration

Abstract

A never event is a serious and preventable error in healthcare. Wrong route drug administration into the arterial line can cause significant injury to the patients hand. Analysis of the incident data showed errors occurred during levels of heightened stress when medication was required to be given urgently, however during these circumstances healthcare workers did not seem to recognize the arterial line despite being coloured differently to standard venous lines. By using human factors design principles it was possible to develop a solution which prevents wrong route drug administration into the arterial line and does not interfere with normal clinical practice. We highlight that it was possible to eliminate a serious error in healthcare around the world.