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 was not opened and the patient was not therefore receiving oxygen. Peri-arrest on arrival, 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.