Risk of harm from inappropriate placement of pulse oximeter probes

A warning alert has been issued on the risk of harm from inappropriate placement of pulse oximeter probes.

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

About this Alert

Measurement of oxygen saturation, using a pulse oximeter probe, is routinely undertaken as part of patients’ vital signs during diagnosis and ongoing monitoring. 

Oximeter probes can be single or multiple use and are designed to attach to specific parts of the body. Adult oximeter probes can be attached to either a finger or an ear, but are not interchangeable between these sites, whilst probes for babies and children need to be selected according to the patient’s weight.

If an oximeter probe intended for the finger is attached to the ear (or vice versa), or a probe intended for an adult is attached to a baby or a child (or vice versa), it can produce a reading up to 50% lower or 30% higher than the real value. 

This alert asks providers to ensure staff have access to appropriate equipment and the information they need to use these devices safely.

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