New guidance, produced by the National Patient Safety Agency (NPSA) and NHS organisations across England and Wales, has been released aimed at ensuring safer systems are in place to treat patients needing oxygen.
The alert to all NHS acute, community and mental health organisations, as well as the independent sector, follows reports received by the NPSA of 281 serious incidents between December 2004 and June this year. Of these incidents, poor oxygen management appears to have caused nine deaths and may have contributed to a further 35 deaths. Common incidents that were highlighted include: • Failure or wrongly prescribed dosage. • Failure to monitor oxygen blood concentration. • Confusion of oxygen with compressed air. • Empty cylinders, faulty and missing equipment. Dr Kevin Cleary, NPSA’s medical director, said: “Oxygen is one of the most common medicines given to thousands of patients each day, across England and Wales, and most is given safely. However, because of a lack of awareness, oxygen is often given without any prescription and patients are attached to oxygen tubing with no documentation of their medicine on their treatment chart. “We have received reports of incidents where oxygen cylinders were empty or patients were harmed when oxygen and air outlets were confused. Our recommendations should make systems safer by reducing reliance on cylinders and reminding staff of the need to follow clinical guidelines in safe prescribing, administration and monitoring of patients on oxygen.” One NHS organisation that has made huge changes in the way it manages oxygen use, over recent years, is Colchester University Hospital NHS Foundation Trust. Biomedical engineer, Steve Connew, said: “We have taken this matter extremely seriously as poor working practices can have an adverse effect on the health and safety of patients and staff as well as wasting valuable resources. “Over the past year, we have held over 130 safe use and handling medical gas courses to staff who are involved in providing oxygen to patients. They range from porters to frontline clinicians, and we’ve noticed a significant reduction in the amount of oxygen wastage and cylinder stockholding. We have also asked staff to ensure flow meters and cylinder valves are turned off when not in use.”
