National patient safety alert – risk associated with adult breathing circuits lacking a patent exhalation route

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This joint national patient safety alert has been issued by the NHS England National Patient Safety team, in collaboration with the Faculty of Intensive Care Medicine, regarding the risk of harm from incorrectly assembled breathing circuits lacking proper exhalation routes for patients receiving invasive or non-invasive ventilatory support.

Organisations caring for patients on invasive and non-invasive breathing circuits are required to develop local guidance and visual aids for circuit assembly, implement training on specific safety checks, and establish clear communication processes.

All actions must be completed within 6 months.

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National patient safety alert – risk associated with adult breathing circuits lacking a patent exhalation route

National patient safety alert – risk associated with adult breathing circuits lacking a patent exhalation route

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Published 11 December 2025.

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National patient safety alert – risk associated with adult breathing circuits lacking a patent exhalation route

National patient safety alert – risk associated with adult breathing circuits lacking a patent exhalation route

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Summary

PDF version.

Published 11 December 2025.