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 issues where ventilators had been left in standby mode.
The team reviewed a Serious Incident report describing a patient who went into cardiac arrest shortly after being transferred from a transport ventilator to a bedside critical care ventilator, which had been left in standby mode.
Standby mode is used when a ventilator is first switched on and the settings are confirmed before connecting to the patient, or when ventilation needs to be briefly suspended. A review of the NRLS over a three-year period found 13 related incidents. Ventilators were most commonly left in standby during handover when admitted / returning to critical care, when changing ventilator settings, or during physiotherapy.
As a result of these findings, the Faculty of Intensive Care Medicine (FICM) plan to publish a critical care handover ventilation checklist to prompt staff to actively check that the ventilator is taken out of standby, and the patient is being ventilated.
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.