Ensuring oxygen delivery when using two step humification systems

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 a patient safety issue around the initiation of humidified oxygen treatment.

Oxygen is sometimes administered to patients with the addition of a humidification system to warm and moisten the oxygen being inspired by the patient.

There are a variety of humidification systems. Some incorporate a 2-step process where a gauge on the device allows the percentage of inspired oxygen (FiO2) to be varied, whilst receiving oxygen via the oxygen flowmeter. Both FiO2 and litres per minute need to be set to give effective treatment.

A patient needed humidified oxygen as part of their treatment. Staff attached the humidification mask and set the gauge to the required FiO2 however omitted to turn on the oxygen at the flowmeter. It was not recognised that the patient was not receiving oxygen and they sadly later died.

A review of similar cases identified incidents describing incorrect settings of the oxygen flowmeter or the FiO2 gauge of the device, or both. Incidents describe patients receiving the incorrect amount of oxygen leading to deterioration and reduction of oxygen saturation.

In the absence of a hard barrier to eradicate this risk, the National Association of Medical Device Educators and Trainers (NAMDET) were contacted and agreed to recommend their members review what devices are used within organisations and ensure understanding and competency in their use through local training. This recommendation was published within the MDET journal (Volume 3, Issue 2).

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.