Risk of death and severe harm from failure to obtain and continue flow from oxygen cylinders

A warning alert has been issued on the risk of death and severe harm from failure to obtain and continue flow from oxygen cylinders.

Patient Safety Alerts are shared rapidly with healthcare providers via the Central Alerting System (CAS).

About this Alert

The design of oxygen cylinders has changed over recent years with the intention to make them safer to use. Cylinders with integral valves are now in common use and require several steps (typically removing a plastic cap, turning a valve and adjusting a dial) before oxygen starts to flow. To reduce the risk of fire valves must be closed when cylinders are not in use, and cylinders carried in special holders that can be out of the direct line of sight and hearing of staff caring for the patient.

An unintended consequence of these changes is that patient safety incidents have occurred where staff believed oxygen was flowing when it was not, and/or they have been unable to turn on the oxygen flow in an emergency.

This alert asks providers that use oxygen cylinders to determine if immediate local action is needed to reduce the risk of these incidents, and to ensure an action plan is underway to support staff to prevent them.

Different manufacturers and models of oxygen cylinders use different control designs. NHS Improvement and the Medicines and Healthcare products Regulatory Agency (MHRA) are supporting the distribution of training materials and resources for different manufacturers’ designs of oxygen cylinder via the Medication Safety Officer (MSO) and Medical Device Safety Officer (MDSO) networks.

The Health Safety Investigation Branch (HSIB) is also currently conducting an investigation into this safety issue.

June 2018 progress update

We have been made aware of a number of educational resources and design changes that have been made/produced to support the alert’s recommendations.

Design changes
Oxygen cylinder manufacturer BOC, will be printing a message on the tamper evident seal advising users that the plastic pull tag must be pulled and the cap removed before the cylinder is used. They are also considering the possibility of putting a message on the plastic cover that protects the fir tree outlet that oxygen tubing is connected to. This message will provide basic instructions to connect the equipment to either the fir tree or Schrader outlet; open the cylinder valve (using the black hand wheel); and to select a flow (with the top flow selector) to administer the gas to the patient.

These modifications have been discussed with the MHRA. Further information can be accessed on the BOC website.

A smart phone application is also available which calculates the estimated time remaining/gas available in a cylinder when the cylinder barcode is scanned and a flow rate is selected.

Educational resources
Most providers of oxygen cylinders have issued educational resources and step-by-step guides for how to safely and effectively use their oxygen cylinders. The majority have sent a notification to all NHS trusts on how to access e-learning platforms. Some also have free e-learning available on their websites, along with downloadable supporting user instructions and cylinder flow rate charts.

BOC have also produced an ‘Instructions for use’ YouTube video

At a local level, healthcare organisations have been able to link into their appointed Medication Safety Officer (MSO) and Medical Device Safety Officer (MDSO).

Following the issuing of the alert, a well-attended national MSO/MDSO WebEx was held. The WebEx signposted to resources from all manufacturers and relevant points from NHS estates guidance for medical gas pipeline systems (HTM 02-01); highlighted guidance and resources showing oxygen cylinder use and flow rate/duration; and shared local initiatives that have been put in place in response to the alert.  All resources are available through the MSO/MDSO Forum (access via MSO/MDSO network members).

Although MSO/MDSOs are predominantly based within an acute hospital, some are also based in primary care, mental health organisations and the community.  Further details of who your organisation's MSO or MDSO is can be obtained at organisational level or by contacting the MHRA safetyalerts@mhra.gov.uk

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