Our latest report, published 28 February 2019, highlights that despite ongoing work, NHS trusts may face barriers when responding to national patient safety alerts.
We have focused on how patient safety alerts are designed and how advice is given to providers to implement them. This follows an investigation on safety risk of connecting patients to the piped medical air supply instead of the oxygen supply in hospitals. We identified a case where this happened to an 85-year old woman whilst she was receiving treatment following a fall at home.
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).
NHS Improvement had recognised this risk and issued a patient safety alert in 2016, asking trusts to reduce the risk of oxygen tubing being connected to airflow meters and setting out actions and barriers that could be put in place.
The investigation found that 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.
As a result, a recommendation has been made to the National Patient Safety Alert Committee (NAPSAC) as follows:
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.
NAPSAC's response to the recommendation will be published on our piped supply of medical air and oxygen investigation page when it's available.
Medical Director’s statement
Dr Kevin Stewart, Medical Director at HSIB, said: “Our investigation highlighted that despite the work that has gone into this, we are still seeing the same issues. In this particular case, as well as finding that there is a lack of clarity over the need for piped medical air in hospitals, financing and resourcing might also be a systemic barrier for trusts.
“Although the patient in this case wasn’t harmed, there could have been a very different outcome. Rather than equipment design, we felt that it would be more effective for our recommendation to feed into the work being done by the National Patient Safety Alert Committee.”