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 made a safety recommendation to the National Patient Safety Alert Committee as a result of this investigation. They responded to the safety recommendation within 90 days of the publication of the investigation report, as requested.

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.

Response received 14 May 2019:

As chair of the National Patient Safety Alert Committee, whose members include all arms-length bodies and teams who issue national safety guidance in the form of alerts, I [Dr Aidan Fowler] welcome the recommendation from HSIB. 

I can confirm that the standards that the National Patient Safety Alert Committee (NaPSAC) agreed in 2018 include, amongst other criteria, that: “There is a procedure for the development of actions required in the National Patient Safety Alert that includes: an assessment of the actions for potential unintended consequences is carried out [and] an assessment of the likely effectiveness of the actions in reducing future harm is carried out.” 

These standards also include a requirement that “The system [of each alert-issuing body] sets out what types of supporting materials should be provided by the alert issuing team/body for complex National Patient Safety Alerts.” This requirement encompasses materials to support providers with implementation and ongoing monitoring where this is required; we would not expect this support to be required for some National Patient Safety Alerts that are straightforward (for example, some types of drug or device recall) or National Patient Safety Alerts that contain systemic actions that once taken eliminate the need for ongoing monitoring. A key aspect of the work of NaPSAC is the role of CQC [Care Quality Commission] in inspecting compliance with National Patient Safety Alerts and where appropriate using its regulatory powers.

The NaPSAC standards became active on 13 May 2019 and the first alert-issuing body is currently preparing its application to become a credentialled issuer of National Patient Safety Alerts. Progress will be publicly reported on the National Patient Safety Alert Committee webpages

Safety observations

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.

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.

Response received 14 May 2019:

Whilst the Medicines and Healthcare products Regulatory Agency (MHRA) remains the lead for the Central Alerting System, the National Patient Safety Alert Committee (NaPSAC) will advise on the route for the dissemination and response to National Patient Safety Alerts. A NaPSAC workshop held in January 2019 identified that a function to record information on actual action taken is one of the key characteristics of a future system that stakeholders propose, and NaPSAC will continue to work with all partners, including MHRA, to improve systems for the dissemination of National Patient Safety Alerts.