We made a safety recommendation to the National Patient Safety Alert Committee as a result of our investigation into the piped supply of medical air and oxygen.

Safety recommendation

We recommended that 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.

This safety recommendation was made as a result of our investigation into the piped supply of medical air and oxygen. We were made aware of 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 and a Rapid Response Report from the National Patient Safety Agency intended to address this issue.

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.

Response from the National Patient Safety Alert Committee

Dr Aidan Fowler, National Director of Patient Safety – NHS England and NHS Improvement, said: “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 welcome the recommendation from HSIB”.

The National Patient Safety Alert Committee has now introduced a set of standards – agreed in 2018 – for National Patient Safety Alerts. 

Read Dr Fowler’s full response to this safety recommendation and download the investigation report on the piped supply of medical air and oxygen investigation page.