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Alert issued to NHS on incorrect use of oxygen cylinders risking patient death

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NHS employers are being urged to ensure nurses and other clinicians know how to operate oxygen cylinders correctly, after a number of incidents in which patients died due to their incorrect use.

In recent years the design of the cylinders has changed, meaning staff may believe oxygen is flowing when it is not, or they are unable to turn the flow on in an emergency.

“Staff appeared to assume the same single step to start piped oxygen flowing (turning the flowmeter dial) also applies to cylinders”

NHS Improvement

Cylinders with integral valves are now in common use but require several steps to be taken before oxygen is released, typically involving removing a plastic cup, turning a valve and adjusting a dial.

Between January 2015 and October 2017, more than 400 safety incidents were reported to the NHS’s internal monitoring system following incorrect operation of oxygen cylinders.

Six patients died, although most were already critically ill and may not have survived even if their oxygen supply had been maintained, according to the health service’s National Reporting and Learning System.

Five patients had a respiratory and/or a cardiac arrest but were resuscitated, and four became unconscious. In addition, other reports have described patients experiencing difficulty breathing and low oxygen saturations that required urgent medical attention.

“The green indicator showing a full cylinder appeared to be misinterpreted as an indicator of active flow”

NHS Improvement

Most staff reporting incidents believed that the cylinder involved was either faulty or empty, and only later was it discovered that the cylinder controls had not been operated correctly.

“Staff appeared to assume the same single step to start piped oxygen flowing (turning the flowmeter dial) also applies to cylinders,” said a patient safety alert published by regulator NHS Improvement.

“They also appeared confused by aspects of the cylinder’s design: no clear indicator on the valve showing the open and closed positions, and the plastic cap hiding controls,” it said. “The green indicator showing a full cylinder appeared to be misinterpreted as an indicator of active flow.” 

The incidents have involved portable oxygen cylinders of all sizes on trolleys, wheelchairs, resuscitation trolleys and neonatal resuscitaires – plus larger cylinders in hospital areas without piped oxygen.

NHS Improvement has issued a patient safety alert today, calling on healthcare employers to support staff to use the cylinders in the correct way.

“NHS Improvement is calling on all providers to take immediate action to determine if steps are needed to prevent these incidents”

Kathy McLean

It said employers should consider prioritising training for staff in clinical areas that are more at risk of an incident occurring and provide regular opportunities to practise using the cylinders.

They should also raise awareness of the issue at the same time as other risks, such as fire hazards and cylinder duration limits, and place laminated guides in the areas they are being used.

Dr Kathy McLean, executive medical director at NHS Improvement, said: “It is vital that NHS staff are appropriately supported to correctly use these designs of oxygen cylinders.

“That’s why NHS Improvement is calling on all providers to take immediate action to determine if steps are needed to prevent these incidents and that action plans are underway to reduce this risk,” she said

“This alert showcases the importance of the National Reporting and Learning System in highlighting issues that require national action to support the NHS to keep patients safe,” she added.

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