Our national learning reports can be used by healthcare leaders, policymakers, and the public to:

  • Aid their knowledge of systemic patient safety risks
  • Understand the underlying contributing factors
  • Inform decision making to improve patient safety
  • Explore wider patient safety processes

The information in national learning reports is also used to inform future HSIB investigations or programmes of work.

Coronavirus (COVID-19) can cause severe inflammation of the lungs affecting a patient’s ability to breathe and meet their oxygen requirements. As a result, an increased number of patients have required oxygen therapy to manage the respiratory failure associated with COVID-19.

Oxygen and COVID-19

This national learning report will describe patient safety risks associated with the use of both portable oxygen systems (cylinders) and piped oxygen supplies (via a wall port built into the hospital infrastructure).

Data sources including published and unpublished HSIB investigation work are being reviewed. This has highlighted that although attempts have been made to manage these safety risks, incidents resulting in serious harm and death continue to happen during the COVID-19 response.

National learning report summary

This national learning report will highlight:

  • That existing approaches to improving safety associated with the use of oxygen, including patient safety alerts and HSIB safety recommendations, have not achieved their intended effects.
  • That the COVID-19 response brought together a combination of circumstances and factors that exposed pre-existing deficiencies in safety systems.
  • Ongoing risks that may be amenable to further action by stakeholders and manufacturers.

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