NHS Issues Patient Safety Alert

News From: www.improvement.nhs.uk

Some patients need to be given additional oxygen as part of their treatment. Where there is no access to piped or concentrated oxygen, it is provided in cylinders, the design of which has changed over recent years. Cylinders with integral valves are now in common use and require several steps (typically removing a plastic cap, turning a valve and adjusting a dial) before oxygen starts to flow. To reduce the risk of fire valves must be closed when cylinders are not in use, and cylinders carried in special holders that can be out of the direct line of sight and hearing of staff caring for the patient.

An unintended consequence of these changes is that staff may believe oxygen is flowing when it is not, and/or may be unable to turn the oxygen flow on in an emergency.

In a recent three-year period, over 400 incidents involving incorrect operation of oxygen cylinder controls were reported to the National Reporting and Learning System (NRLS). Six patients died, although most were already critically ill and may not have survived even if their oxygen supply had been maintained. Five patients had a respiratory and/or a cardiac arrest but were resuscitated, and four became unconscious. Other incident reports described patients experiencing difficulty breathing and low oxygen saturations that required urgent medical attention. Incidents involved portable oxygen cylinders of all sizes on trolleys, wheelchairs, resuscitation trolleys and neonatal resuscitaires, and larger cylinders in hospital areas without piped oxygen. 

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