Operative Neurosurgery 29:345–350, 2025
This systematic review examines misadministration events involving external ventricular drains (EVDs), including the first reported case of blood transfusion through an EVD. It highlights risk factors, advocates for ISO 80369-6 NRFit connectors to prevent misconnections, and recommends enhanced protocols and staff education to improve patient safety.
• External ventricular drains (EVDs) are widely used in neurosurgery but carry risks of misadministration due to connector similarity with IV lines.
• A systematic review identified 7 reports (8 cases) of EVD misadministration, involving drugs like gadolinium, anesthetics, antiepileptics, and, for the first time, blood products.
• The first reported case of blood transfusion into an EVD resulted in patient death, highlighting the severity of such errors.
• Main contributing factors include unfamiliarity with EVD systems, similar appearance to IV tubing, and poor visibility during procedures.
• The new ISO 80369-6 standard and NRFit connectors, with a smaller diameter than Luer connectors, are designed to prevent misconnections.
• Adoption of NRFit connectors, staff training, and clear equipment labeling are key recommended preventive strategies.
• Current guidelines from professional organizations support design changes and staff education but lack universal protocols for EVD management.
• Further research and widespread implementation of standardized connectors are needed to improve patient safety.
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