Eliminating the risk of inadvertent connection to medical air via a flowmeter

A National Patient Safety Alert has been issued asking all providers that use piped medical air to eliminate the risk of inadvertently connecting patients to medical air via a flowmeter instead of oxygen.

About this alert

Air flowmeters attached to piped medical air outlets are primarily used to drive the administration of nebulised medication; typically for short periods to manage respiratory conditions. Most other uses of piped medical air do not require an air flowmeter.

Due to the proximity of the piped medical air and oxygen outlets at the bedside, and the similarity in design of flowmeters, there is a significant risk when using air flowmeters that patients may be inadvertently connected to medical air instead of oxygen.

The alert asks providers to purchase alternative devices that do not require medical air to be delivered via an air flowmeter. Following this, all medical air flowmeters except those tethered to equipment for niche use should be discarded, and all medical air outlets no longer required should be reversibly capped off.

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 was 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.

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

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