Delayed oxygenation of neonate during resuscitation when oxygen not ‘flicked’ on

Through its core work to review patients safety events recorded on national systems, such as the National Reporting and Learning System (NRLS), the new Learn from Patient Safety Events service (LFPSE), and other sources, the National Patient Safety Team identified an issue relating to delayed oxygenation during neonatal resuscitation due to the medical gases switch on the infant resuscitation unit not being turned on.

The Resuscitation Council UK Guidelines on Resuscitation and support of transition of babies at birth recognises that ensuring an open airway, aerating and ventilating the lungs is usually all that is necessary to successfully resuscitate a new-born baby and without these, other interventions will be unsuccessful.

There are different models of infant resuscitation units in use. The front panel has a number of controls for medical gas delivery, suction and infant warming which are generally separate and each requiring a switch to be ‘flicked on’ to work. There is no apparent standardisation of the front panel layout including where these switches are located.

A review of similar incidents highlighted the design of infant resuscitation units as a potential concern. We shared this insight with the British Standards Institute and asked that post market usability error data, specifically around potential design weaknesses, are incorporated into the development and review of future improvements to the design of these devices. We also shared this with CAPA , the clinical and product assurance arm of NHS Supply Chain who are implementing a NHS Supply Chain Essential Specification Programme which will adopt a human factors and ergonomics approach to procuring products for the NHS.

About our patient safety review and response work

The recording and central collection of patient safety events to support learning and improvement is fundamental to improving patient safety across all parts of NHS healthcare.

A core part of the work of the National Patient Safety Team is to review these records to identify new or under recognised patient safety risks, which are often not obvious at a local level. In response to any newly identified risks, we develop advice and guidance, such as National Patient Safety Alerts, or work directly with partners as in the example above, to support providers across the NHS to take the necessary action to keep patients safe.

You can find out more about our processes for identifying new and under recognised patient safety issues on our using patient safety events data to keep patients safe and reviewing patient safety events and developing advice and guidance web pages.

You can also find more case studies providing examples of this work on our case study page.