Summary
This article looks at a safety issue around the initiation of humidified oxygen treatment. It examines an incident which resulted in a patient's death when they did not receive oxygen.
NHS England: Ensuring oxygen delivery when using two step humification systems
https://www.england.nhs.uk/patient-safety/using-patient-safety-events-data-to-keep-patients-safe/how-we-acted-on-patient-safety-issues-you-recorded/ensuring-oxygen-delivery-when-using-two-step-humification-systems/
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