Warning of oxygen cylinder errors amid pressure on the NHS | NHS

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The pressures on health services in England may have contributed to a number of patient safety incidents involving oxygen cylinders, according to an NHS warning.

Released after 120 incidents related to hardware problems. The errors, which were recorded within the last 12 months, included staff giving patients empty cylinders or not replacing cylinders.

In some cases, the blunders “impeded” the delivery of oxygen to patients, leading to “serious deterioration and cardiac or respiratory arrest”, according to NHS England.

The alert states that severe stress on the health system, particularly when there are mutations in respiratory diseases such as influenza and the Covid-19 virus, can lead to increased use of oxygen cylinders as medical gas pipeline systems cannot be reached. This may mean that people needing oxygen are treated in a corridor or side room that is not connected to the main supply system.

The alert adds that the increase in demand “adds to the known risks associated with the use of oxygen gas cylinders.”

Other errors related to “improper” transportation of discs or devices not properly secured were recorded.

The document, issued to A&E departments and ambulance funds, also states that “there is a need to maintain oxygen cylinder use to ensure a robust supply chain operation.”

The trusts have been asked to ensure that risk assessments are conducted “in all areas where acute patients are being cared for (either temporarily or permanently) without routine access to medical gas pipeline systems.”

The document says: “In the last 12 months (the NHS in England) has identified 120 patient safety incidents, including those with these subjects: cylinder empty at point of use; cylinder not actuated; cylinders improperly moved; cylinders improperly secured.” Some of these reports described impaired oxygen delivery to the patient, resulting in serious deterioration and cardiac or respiratory arrest.

“During periods of high stress, often exacerbated by a rise in respiratory conditions, the demand for supplies of oxygen cylinders, especially smaller sizes, increases in the NHS due to the need to provide basic oxygen treatment in areas where medical gas pipeline systems are not available.

This increase in demand increases the known risks associated with the use of oxygen gas cylinders. As a result of the current pressures on the NHS, NHS England has issued to providers a summary of best practices on the safe use of oxygen cylinders.”

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