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Publication Type: Patient Safety Alert
Single or Multiple Incident: Multiple
Date: 10/4/2016 12:00:00 AM
Country: United Kingdom
Organization: NHS Commissioning Board

This alert discusses the severe patient safety incidents, including death, that can occur when medical air is accidentally administered to patients instead of oxygen. Although the issue was raised through multiple sources in 2008 and 2009, incident continue to be reported. One incident is described. “…Patient arrested a further time secondary to hypoxia. It was then discovered that patient was inadvertently being ventilated with medical air from piped supply for up to ten minutes. The medical air and the oxygen outlets were side by side, both with flowmeters attached. It was very difficult to tell which flowmeter was which, particularly in an emergency situation.” Air and oxygen flowmeters can be difficult to tell apart and as they both have universal outlets, oxygen tubing can be attached to both. Three barriers to human error have already been recommended by the National Patient Safety Agency (NPSA) and British Thoracic Society (BTS) but continuing incidents suggest they have not been universally implemented. These barriers are included in the recommendations provided to reduce the likelihood of patient safety incidents occurring with the use of oxygen and medical gases. Recommendations to prevent similar incidents are provided.

Additional Details

oxygen tubing, air flowmeter, electric compressor, ultrasonic nebulizer
oxygen medical gas, medical air

Reducing the risk of oxygen tubing being connected to air flowmeters