A National Patient Safety Alert has been issued on the risk of harm from interruption of high flow nasal oxygen (HFNO) during transfer.
About this alert
This alert relates to the risk of harm caused by the interruption of HFNO to babies, children and adults in acute respiratory failure without hypercapnia during patient transfer. Some HFNO delivery devices have a transport mode, but most require mains power and will not deliver oxygen during transfer unless attached to a compatible uninterruptible power supply (UPS) device.
The alert asks providers to add clear labels to HFNO delivery devices to make staff aware that even brief interruptions to mains power supply could lead to respiratory and cardiac arrest; and that HFNO in any emergency department or short stay unit must not be started without a plan for how to transfer the patient onwards.
Where a UPS is used, action must be taken on the storage and maintenance of UPS devices to ensure they are ready for use and staff know where to locate them.
About National Patient Safety Alerts
This alert has been issued as a National Patient Safety Alert.
The NHS England and NHS Improvement patient safety team is the first national body to have been accredited to issue National Patient Safety Alerts by the National Patient Safety Alerting Committee (NaPSAC). All National Patient Safety Alerts are required to meet NaPSAC’s thresholds and standards . These thresholds and standards include working with patients, frontline staff and experts to ensure alerts provide clear, effective actions for safety-critical issues.
NaPSAC requires providers to introduce new systems for planning and coordinating the actions required by any National Patient Safety Alert across their organisation, with executive oversight.
Failure to take the actions required under any National Patient Safety Alert may lead to CQC taking regulatory action.