The design of oxygen cylinders has changed over recent years with the intention to make them safer to use. 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.
Ensuring oxygen continues to flow
An unintended consequence of these changes is that patient safety incidents have occurred where staff believed oxygen was flowing when it was not, and/or they have been unable to turn on the oxygen flow in an emergency.
This alert asks providers that use oxygen cylinders to determine if immediate local action is needed to reduce the risk of these incidents, and to ensure an action plan is underway to support staff to prevent them.
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. A typical incident report reads: “Patient arrived on coronary care unit with oxygen saturations of 72%. Oxygen in situ and set to correct rate on the flow dial but unfortunately [the valve] was not opened and the patient was not therefore receiving oxygen. Peri-arrest on arrival, [crash team] called condition improved. The registered nurse continued to check that the cylinder was not running out but failed to notice not turned on as indicator green.”
Insights from local investigations include:
- prioritising training for staff groups and clinical areas where the risk is high.
- reinforcing theoretical training with regular opportunities to practise operating the cylinder controls.
- linking safe operation of cylinder controls with other key safety issues, including fire hazards and how long a full cylinder will last on various flow rates.
- placing laminated guides close to the point of use. These can easily be prepared in advance to be immediately available when needed.
NHS Improvement and the Medicines and Healthcare Products Regulatory Agency (MHRA) are supporting the distribution of training materials and resources for different manufacturers’ designs of oxygen cylinder via the Medication Safety Officer (MSO) and Medical Device Safety Officer (MDSO). The MHRA will continue to work with industry partners to improve oxygen cylinder design. The Healthcare Safety Investigation Branch (HSIB) is also currently conducting an investigation into this safety issue.
The manager should ensure all staff responsible for using oxygen cylinders receive training regularly and can demonstrate that they understand the controls on the cylinder. Providers should recognise hands on practice is the most effective way of ensuring competence so give staff the opportunity to handle and operate the controls on a regular basis.
Although evidence from this NHS Alert relates to patients in hospital settings, the safety issues highlighted when staff are using oxygen cylinders may be equally relevant to where they are in use in care homes or community settings.
Safety is of paramount importance to all aspects of care. This alert asks providers that use oxygen cylinders to determine if immediate local action is needed to reduce the risk of these incidents, and to ensure an action plan is underway to support staff to prevent them.
Managers of social care services can do well to learn from the insights into local investigations and ensure their policies and procedures take account of the guidance given in this NHS Alert.
Albert Cook BA, MA & Fellow Charted Quality Institute
Bettal Quality Consultancy