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.

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