This investigation focuses on the design and implementation of patient safety alerts. It follows a reference event where an 85-year old woman was connected to the piped medical air supply, instead of the oxygen supply, whilst she was receiving hospital treatment after a fall at home.

Investigation summary

We were made aware of a safety issue relating to a persistent risk in hospitals of connecting oxygen tubing to wall-mounted air flowmeters, despite the release of a Patient Safety Alert by NHS Improvement in 2016 and a Rapid Response Report from the National Patient Safety Agency in 2009 intended to address this issue.

Since being classified as a never event – a serious incident that is entirely preventable – in February 2018, 32 cases of unintentional connection to air instead of oxygen have been reported (1 February 2018 to 30 June 2018). 

The investigation found that NHS trusts may have misinterpreted the direction of the alert and that the central alerting system doesn’t capture the detail of actions taken by providers in response to alerts.

Safety recommendations

We’ve made a safety recommendation to the National Patient Safety Alert Committee as a result of this investigation.

We expect that they will respond to their recommendation within 90 days of the publication of the investigation report. Their response will be published here when it’s available.

National Patient Safety Alert Committee

Recommendation 2019/027

The National Patient Safety Alert Committee should set standards for all issuers of patient safety alerts that require an assessment for unintended consequences, the effectiveness of barriers in the alert, and the advice the alert issuers give providers on implementation and ongoing monitoring.

Safety observations

This investigation makes the following safety observation:

The Central Alerting System gives providers the opportunity to supply information on actual actions taken alongside recording that actions have been completed. However, the functionality could be developed to require providers to give further detail and this would allow a more effective way of nationally reviewing this information.

Safety observations are made when there is insufficient or incomplete information on which to make a definitive recommendation for action, although findings are deemed to warrant attention.

Find out more by reading our report launch news story.