Alert over hospital air devices after 120 ‘never events’

NHS trusts are to be told to remove devices linked to more than 120 never events caused by ‘unconscious errors’.

A national patient safety alert from NHS England which urges trusts to remove all air flowmeters from wall medical gas outlets. It is likely to be published next month.

The alert comes after 121 never events in the last three years involved staff members accidentally connecting patients to air instead of oxygen. This number is close to 10% of all never events recorded during that period.

These types of never events have been recorded by 57 NHS organisations during 2018-19, 2019-20 and 2020-21.

The incidents took place mostly on medical wards and in emergency departments. They occurred despite NHSE issuing a patient safety alert in 2016, which recommended removing the flowmeters from wall outlets when not in active use.

According to NHSE documents - seen by HSJ - the never events often went undetected “for some time”, even when other staff responded to deteriorating patients or took over their care. The regulator concluded this makes it more likely that there have been other unreported incidents.

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Source: HSJ, 17 May 2021