Patient safety alert after 120 incidents linked to oxygen cylinder problems

Pressures on the health service could have contributed to a number of patient safety incidents involving oxygen cylinders, according to a new NHS alert.

Officials issued the alert after 120 incidents were linked to problems with the devices.

The errors, which have been recorded over the last 12 months, include staff giving patients empty cylinders or failing to switch cylinders.

In some instances blunders have “compromised” the delivery of oxygen to patients, which has led to “serious deterioration and cardiac or respiratory arrest”, according to NHS England.

The alert states that extreme pressure in the health system – particularly when there are surges in respiratory illnesses including flu and Covid-19 – can lead to an increased use of oxygen cylinders in areas that are not hooked up to medical gas pipeline systems.

This might mean people who need oxygen being treated in a corridor or a side room that is not connected to the main supply system.

The surge in demand “increases the known risks associated with the use of oxygen gas cylinders”, the alert adds.

Other errors have been recorded due to the “inappropriate” transportation of cylinders or not securing the devices properly.

The document, issued to A&E departments and ambulance trusts, also states that “there is a need to conserve oxygen cylinder use to ensure a robust supply chain process”.

Trusts have been asked to ensure that risk assessments are done to “in all areas where patients are being acutely cared for (either temporarily or permanently) without routine access to medical gas pipeline systems”.

The document says: “In the last 12 months (the NHS in England) identified 120 patient safety incidents, including those with these themes: cylinder empty at point of use; cylinder not switched on; cylinders inappropriately transported; cylinders inappropriately secured.

“Some of these reports described compromised oxygen delivery to the patient, leading to serious deterioration and cardiac or respiratory arrest.”

It adds: “During periods of extreme pressure, often exacerbated by a surge in respiratory conditions, demand on supplies of oxygen cylinders, especially the smaller sizes, increases in the NHS due to the need to provide essential oxygen treatment in areas without access to medical gas pipeline systems.

“This surge in demand increases the known risks associated with the use of oxygen gas cylinders.

“As a result of current pressures on the NHS, NHS England issued providers with a summary of best practice guidance on the ‘Safe use of oxygen cylinders’.”

An NHS England spokesman said: “These patient safety incidents reported over the last 12 months are unrelated to the current surge in demand for portable oxygen cylinders or current pressures on hospitals.

“The NHS issued this alert to remind trusts of best practice for using oxygen cylinders at a time when there are high numbers of patients in hospital with respiratory conditions and the public should continue to come forward for care in the usual way, through 999 in an emergency and otherwise use 111 online.”