Risk of severe harm and death from unintentional interruption of non-invasive ventilation

A stage one warning has been issued to raise awareness of unintentional interruption of non-invasive ventilation (NIV).

The National Reporting and Learning System (NRLS) has identified patient safety incidents where harm has been caused when the oxygen supply was found to be disconnected. Some non-invasive ventilators may not have alarms to warn staff of delivery problems, and if they have, they may have been disabled by staff for various reasons. As devices may differ in their modes of operation it is important that staff are familiar with the specific functions of the equipment being used and that patients receiving NIV are monitored.

Dr Mike Durkin, NHS England Director of Patient Safety, said: “Our national reporting system has identified a number of incidents where harm has occurred related to non-invasive ventilation used in hospitals for patients with respiratory illness. It is vital that staff are familiar with the specific devices being used to deliver this therapy as different models have different safety features. This alert re-iterates the need for close monitoring of these patients and calls for organisations to assess this risk and to take immediate action if required.”

Patient safety alerts are shared rapidly with healthcare providers via the Central Alerting System (CAS).

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