National Patient Safety Alert: Eliminating the risk of inadvertent connection to medical air via a flowmeter (16 June 2021)

Summary

Air flowmeters attached to piped medical air outlets are primarily used to drive the administration of nebulised medication; typically for short periods to manage respiratory conditions. Most other uses of piped medical air do not require an air flowmeter.

Due to the proximity of the piped medical air and oxygen outlets at the bedside, and the similarity in design of flowmeters, there is a significant risk when using air flowmeters that patients may be inadvertently connected to medical air instead of oxygen. A previous alert and additional communications have sought to minimise the use of air flowmeters by encouraging their replacement with compressor or ultrasonic nebulisers, alongside additional risk reduction methods if air flowmeters remained in use.

However, despite the measures outlined above, 108 Never Events describing unintentional connection were reported in a recent three-year period ; over a third of incidents occurred in emergency departments. Consequences included respiratory arrest, cardiac arrest, collapse (requiring ITU admission and ventilation), and nine incidents of incorrect connection when responding to cardiac arrest, which will have impacted on the chance of successful resuscitation; six patients subsequently died.

Content

Actions

1. Purchase sufficient powered nebuliser devices for use across the organisation; to remove the need for medical air to drive nebulisers via a flowmeter.
2. Remove the need for air flowmeter use in the delivery of humidified air, by purchasing sufficient devices that use ambient air.
3. Review any niche uses of air flowmeters and replace with suitable alternatives. If in exceptional circumstances, an air flowmeter cannot be replaced by an alternative device, ensure the flowmeter is tethered to the equipment.
4. On completion of actions 1,2 and 3, remove and discard all medical air flowmeters except those tethered to equipment for niche use.
5. Reversibly cap off all medical air outlets that are no longer routinely required; secured caps are most appropriate for this.
6. Ensure policies and procedures relating to the prescribing and administration of nebulised medication are updated to reflect this change in practice and that they align with British Thoracic Society (BTS) guidance.