Summary
This investigation from the Healthcare Safety Investigation Branch, focuses on the design and implementation of patient safety alerts. It follows a reference event where an 85-year old woman was connected to the piped medical air supply, instead of the oxygen supply, whilst she was receiving hospital treatment after a fall at home.
Piped supply of medical air and oxygen (HSIB investigation)
https://www.hsib.org.uk/investigations-cases/piped-supply-medical-air-and-oxygen/
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