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Patient safety alert issued over use of non-invasive ventilation


Hospital staff must be familiar with the specific equipment being used to provide patients with non-invasive ventilation, NHS England has warned, in the wake of several fatalities.

It has issued a patient safety alert over the risk of severe harm and death from unintentional interruption of non-invasive ventilation (NIV).

The alert has been issued to raise awareness of the problem, after national monitoring highlighted it as a risk, said NHS England in a statement.

It said the National Reporting and Learning System had identified patient safety incidents where harm has been caused when the oxygen supply was found to be disconnected.

In one incident a mask for NIV was attached to a patient’s face but the ventilation machine had not been switched on. The patient became severely hypoxic and died.

“It is vital that staff are familiar with the specific devices being used to deliver this therapy as different models have different safety features”

Mike Durkin

Three additional fatal incidents involved the oxygen supply being found to be disconnected. In these cases, the length of time the oxygen tubing was detached was unknown, as no regular checking of oxygen tubing was completed and no patient observations were recorded.

The safety alert noted that some non-invasive ventilators may not have alarms to warn staff of delivery problems, and if they have, they may have been disabled by staff for various reasons.

As devices may differ in their modes of operation, it is “important that staff are familiar with the specific functions” of the equipment being used and that patients receiving NIV are monitored, it warned.

Dr Mike Durkin, NHS England’s director of patient safety, said: “Our national reporting system has identified a number of incidents where harm has occurred related to non-invasive ventilation used in hospitals for patients with respiratory illness.

“It is vital that staff are familiar with the specific devices being used to deliver this therapy as different models have different safety features,” he said.

“This alert re-iterates the need for close monitoring of these patients and calls for organisations to assess this risk and to take immediate action if required,” he added.


Readers' comments (8)

  • There are no measures to standardise equipment within NHS for any of the treatments; this leaves patients at risk because staff work in various depts who all use different equipment, should they chose to. Basically reliance on technology has also led to an increase in incidents where patients safety is compromised because of variability in types of equipment/treatment being used.

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  • If you had respiratory therapist managing the bipap/cpap devices most of these incidents would have been found and prevented. Since RTs have to monitor ventilators at least every 2 hours,including oxygen saturation which they must be hooked up to while on the vents

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  • The picture used is terrible - is NT trying to make it look even worse? Nurse writing leaning on wall, patient uncovered and looks uncomfortable, spaces between the bed so tight that IV bags could be touching curtains, is that a brown bag being used as a bin..........

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  • I agree its a horrendous shot, looks like torture!

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  • I agree Having a Respiratory Therapist running the show fro NiV and Invasive Ventilation keeps patients safe rather than having untrained staff managing these patients. That's typical of the NHS management cheap labour give someone 5 minutes of education they think they know it all.

    RT (Respiratory Therapist UK)

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  • there are ideal or optimal solutions for everything to keep the patients as safe as possible but this does not seem to be a government objective where cost would appear the main priority.

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  • It Never happened on my watch

    R Taylor Respiratory Therapist UK

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  • I was a student on a respiratory ward where most patients needed NIV. I asked several nurses who had worked there for over 1 year what NIV was for and how did it work? I was told that they didn't know they just put the mask on and put the machine on and that was it, or I should go and ask the doctor. I was actually quite worried by this and thought this was very unsafe practice.

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