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”
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.