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 with oxygen hoses becoming disconnected from transport ventilators.
An issue raised in a Coroner’s ‘Prevention of Future Death’ report described a critically ill ventilated patient being transferred between hospitals where an oxygen hose was not properly connected to the oxygen cylinder on the transport ventilator. This led to the patient having a cardiac arrest.
The coroner identified that the local critical care network transfer checklist did not include instructions to carry out a ‘tug test’ when the oxygen hose is swapped from wall socket to the oxygen cylinder. A tug test involves tugging the oxygen hose after the probe is plugged into the wall or cylinder socket to ensure it is firmly attached.
As a result, we worked with national partners involved in intrahospital and interhospital transfer of adult, paediatric and neonatal patients to ensure a ‘tug test’ is incorporated into local practice. These partners included Faculty of Intensive Care Medicine (FICM), Intensive Care Society, Safe Anaesthesia Liaison Group, Paediatric Intensive Care Society, and the Ambulance transfer network.
FICM also highlighted this issue in the January 2020 issue of its newsletter ‘Critical Eye’.
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.