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 with the use of ethyl chloride during fetal blood sampling.
An issue arising from a manufacturer’s Field Safety Notice (FSN) was identified regarding the compatibility of ethyl chloride spray and specific amnioscopes during fetal blood sampling (FBS) procedures.
The FBS procedure involves taking a small sample of blood from a baby’s scalp during labour, which is used to identify the presence of acidosis in the blood. It helps midwives and obstetricians assess how well the baby is coping with labour and whether any further intervention is required.
During the FBS procedure, ethyl chloride spray is used on the babies scalp to increase the blood flow to the area. The spray was reported to have left a white ‘plastic residue’ on the surface of the amnioscope and on the fetal scalp. The manufacturer’s investigation identified that ethyl chloride and the ABS (Acrylonitrile Butadiene Styrene) material of the amnioscope may be incompatible. There was no harm reported to mother or baby.
We worked with Royal College of Obstetricians and Gynaecologists (RCOG) to update the FBS Procedure section of their website, which now advises against the use of ethyl chloride spray during an FBS procedure. RCOG were also asked to disseminate the FSN and the supporting advice to members via their weekly bulletin.
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.