A stage three alert has been issued to support NHS providers that supply medical air using medical gas pipeline systems (MGPSs) to reduce the risk of harm from oxygen tubing being connected to air flowmeters.
- Reducing the risk of oxygen tubing being connected to air flowmeters
- Supporting information for patient safety alert: Reducing the risk of connecting oxygen tubing to air flowmeters
This alert has been issued to reduce the risk of harm caused from oxygen tubing being connected to air flowmeters. Severe harm or death can occur if medical air is accidentally administered to patients instead of oxygen.
This short animation explains what actions you need to take.
See how we develop a patient safety alert and why it’s important to report patient safety incidents to the National Reporting and Learning System.
Update to this alert: clarification for neonatal units and delivery suites
The basic principles outlined in this alert remain relevant to neonatal units and delivery units, air flowmeters should not be routinely left in wall outlets. However, we recognise that it will be appropriate in neonatal units and delivery suites to have both air and oxygen flowmeters left constantly in place as part of circuits connected to resuscitation equipment, such as ‘resuscitaires’ and ‘neopuffs’. Air flowmeters set up as part of circuits connected to resuscitation equipment would count as ‘active use’ for the purpose of declaring the actions required by the alert as complete.
Neonatal colleagues have emphasised that best practice would be to use wall or pendent/beam system ports and hoses to the equipment rather than flowmeters, and that a blender should be used to support mixing of air and oxygen supplies. Use of “Y” pieces to support gas mixing is not considered to be safe as the concentration of each gas is not likely to mix in a definable concentration/percentage.