Protecting patients through a diligent approach

Issued last October, Patient Safety Alert number NHS/PSA/D/ 2016/009, Reducing the risk of oxygen tubing being connected to air flowmeters, was targeted at ‘all hospitals (or any other sites) providing NHS funded care that supply medical air using medical gas pipeline systems (MGPSs)’, and warns that ‘severe harm or death can occur if medical air is accidentally administered to patients instead of oxygen’. It sets out a number of steps designed to prevent instances of human error where, due to confusion, or a ‘mix-up’ between medical air and oxygen flowmeters, there is a high risk of patients being given medical air accidentally.

According to the Alert, while a Rapid Response Report (RRR) issued by the National Patient Safety Agency (NPSA) in 20091 highlighted the risk, and requested that Trusts develop action plans to prevent these incidents, events continue to occur. Since January 2013 the National Reporting and Learning System (NRLS) has received two reports of fatalities, two of severe harm, and over 200 of incidents resulting in ‘moderate, low, or no harm’. A recent report reads: ‘…Patient arrested a further time secondary to hypoxia. It was then discovered that the patient was inadvertently being ventilated with medical air from piped supply for up to 10 minutes. The medical air and the oxygen outlets were side by side, both with flowmeters attached. It was very difficult to tell which flowmeter was which, particularly in an emergency situation.’

Difficult to tell apart