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.