Alert on risk with oxygen cylinders

A Patient Safety Alert has been issued by NHS Improvement on ‘the risk of death and severe harm from failure to obtain and continue flow from oxygen cylinders’.

Alert reference number NHS/PSA/W/ 2018/001 (https://improvement.nhs.uk/ news-alerts/failure-to-obtain-andcontinue-flow-from-oxygen-cylinders/) alludes to the fact that where patients need to be given additional oxygen as part of their treatment, and there is no access to piped or concentrated oxygen, it is provided in cylinders, the design of which has changed over recent years. The Alert says:  ‘Cylinders with integral valves are now commonly used, and require several steps (typically removing a plastic cap, turning a valve, and adjusting a dial) before oxygen starts to flow. To reduce the risk of fire, valves must be closed when cylinders are not in use, and cylinders carried in special holders that can be out of the direct line of sight and hearing of staff caring for the patient. 

‘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 that an action plan is underway to support staff to prevent them.’ 

NHS Improvement and the MHRA are supporting the distribution of training materials and resources for different manufacturers’ designs of oxygen cylinder via the Medication Safety Officer and Medical Device Safety Officer networks. The Healthcare Safety Investigation Branch (HSIB) is also investigating this safety issue.

 

 

Other news

Upcoming Events

IHEEM Authorising Engineer Conference

Aston Villa FC
14th March 2018

2018 HEFMA Leadership Forum

Cotswold Waterpark Hotel
10th - 11th May 2018

Design in Mental Health Conference 2018

The National Motorcycle Museum, Coventry Road, Bickenhill, Hampton in Arden, Solihull B92 0EJ, UK
15th - 16th May 2018

HEALTH+CARE

ExCeL London
27th - 28th June 2018

IHEEM 2018

Cardiff City Stadium, Leckwith Road, Cardiff, CF11 8AZ
6th - 7th September 2018

Latest Issue

Health Estate Journal

Health Estate Journal

Feb 2018

Merivaara lights ‘set new standard’ in operating theatres

Register now to apply for regular copies of Health Estate Journal and free access to premium content, as well as our regular newsletters.