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Showing results for tags 'Oxygen / gas / vapour'.
Found 47 results
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News Article
More than 100 maternity staff sue NHS over gas exposure
Patient Safety Learning posted a news article in News
More than 100 maternity staff are taking legal action against a hospital trust after being exposed to what they say were "hazardous" levels of nitrous oxide. The staff, who include midwives and healthcare assistants, all worked at Basildon Hospital in Essex between 2018 and 2023. Symptoms including fatigue, anxiety, headaches and "brain fog" were reported. The trust that runs the hospital has said it "should have acted faster to address the issues". The Mid and South Essex NHS Foundation Trust has already paid out £89,000 in settlements over claims staff were exposed to "excessive and foreseeably dangerous" levels of Entonox, which is often called gas and air. A total of 141 claims have been received, according to the NHS. Entonox is a mixture of nitrous oxide and oxygen that is used as pain relief for women giving birth. According to the claimants, levels of nitrous oxide can build up quickly in maternity units with poor ventilation. The gas enters the atmosphere when birthing mothers exhale, when gas lines are leaky, and when cannisters of nitrous oxide are opened and connected to equipment. Maternity staff were exposed to gas levels up to 30 times higher than the legal workplace exposure limit, an internal hospital report found. For people giving birth, the NHS says gas and air is "generally very safe", and side effects are not expected until after patients have used it for longer than six hours. Read full story Source: BBC News, 18 May 2026 -
Content ArticleThis Maternity and Newborn Safety Investigation (MNSI) safety spotlight shares what they found regarding nitrous oxide decommissioning and offers prompts to help providers keep staff informed and equipment checks consistent.
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News Article
An invisible medical shortage: Oxygen
Patient Safety Learning posted a news article in News
Oxygen is vital to many medical procedures. But a safe, affordable supply is severely lacking around the world, according to a new report. At the height of the Covid-19 pandemic, millions of people in poor nations died literally gasping for breath, even in hospitals. What they lacked was medical oxygen, which is in short supply in much of the world. On Monday, a panel of experts published a comprehensive report on the shortage. Each year, the report noted, more than 370 million people worldwide need oxygen as part of their medical care, but fewer than 1 in 3 receive it, jeopardising the health and lives of those who do not. Access to safe and affordable medical oxygen is especially limited in low- and middle-income nations. “The need is very urgent,” said Dr. Hamish Graham, a pediatrician and a lead author of the report. “We know that there’s more epidemics coming, and there’ll be another pandemic, probably like Covid, within the next 15 to 20 years.” The report, published in The Lancet Global Health, comes just weeks after the Trump administration froze foreign aid programmes, including some that could improve access to oxygen. Boosting the availability of medical oxygen would require an investment of about $6.8 billion, the report noted. “Within the current climate, that’s obviously going to become a bit more of a challenge,” said Carina King, an infectious disease epidemiologist at the Karolinska Institute and a lead author of the report. “We’re not pitting oxygen against other priorities, but rather that it should be embedded within all of those programs and within those priorities,” Dr. King said. “It’s completely fundamental to a functioning health system.” Read full story (paywalled) Source: The New York Times, 17 February 2025 -
News Article
NHS Trust death: Inquest into St Albans woman’s empty oxygen cylinder
Patient Safety Learning posted a news article in News
An inquest into the death of a woman under the care of West Hertfordshire Teaching Hospitals NHS Trust began on Monday 20 January. Cecilia Harper (71) died in Watford General Hospital on 9 February 2022, while being transported from her ward to the radiology department. She had been admitted to the hospital five days earlier. The mother-of-two had reported breathlessness while in hospital, after initially being provided with oxygen via nasal cannula, her oxygen dependency increased and Cecilia was provided with an non-rebreather oxygen mask for the journey and was accompanied by a porter and student nurse. She was conscious when she left the ward, yet by the time she arrived in the ultrasound room she had lost consciousness. A number of medical staff undertook CPR but Cecilia had sadly died. Upon investigation, it was discovered that Cecilia’s oxygen cylinder was empty, it was not clear when this occurred. During the first day of the inquest, it was heard that research carried out by a doctor at the Trust indicated that 10% of patients transferred to the A&E CT department have insufficient oxygen for a return journey, while 9% of patients made the journey with oxygen cylinders switched off. However, a post-mortem report, which identified metastatic breast carcinoma as the cause of death, made no mention of the impact of the empty oxygen cylinder or oxygen dependency. An inquest took place at the Coroner’s Office for the Area of Hertfordshire to determine the cause of Cecilia’s death. There have been two previous inquest review hearings to ensure all appropriate evidence has been sought, which has delayed proceedings. The inquest, which was expected to take place over three days, concluded on Tuesday (21 January). The inquest sought to confirm the exact circumstances surrounding Cecilia’s death. The coroner determined that Mrs Harper died from natural causes, but it is unclear whether there was any problem with oxygen supply, and it is unclear if there was a problem with oxygen supply, if it contributed to her death. Read full story Source: Tees, 21 January 2025 -
Content ArticleThe MHRA has been made aware that falsified medical oxygen has been provided to several dental practices across the UK. The Medicines and Healthcare products Regulatory Authority (MHRA) has been made aware that falsified medical oxygen has been provided to several dental practices across the UK. The source of the supply has been identified as batches provided by Tricodent Limited. An assessment of risk to public health and patient safety has been completed and the risk was found to be low. A criminal investigation into the company that supplied this stock is ongoing. The falsified product in circulation is labelled: Medical Oxygen B.P PL No 04280/0001 MEDIGAS OXYGEN. Advice for healthcare professionals Stop using the product immediately and quarantine all remaining stock. Authorised and licensed suppliers can offer advice regarding disposal of falsified cylinders, do not return cylinders to Tricodent Limited. Advice for patients No further action is required by patients as this is a specific recall for medical oxygen, primarily used by dental practices. This product is administered by healthcare professionals directly. If you have concerns about a medicine you may be using, please contact your healthcare professional.
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News Article
'Catastrophic' consequences after oxygen error
Patient Safety Learning posted a news article in News
A patient in north Wales suffered "catastrophic" consequences when staff didn't connect their oxygen supply correctly. The Betsi Cadwaladr health board, which was caring for the patient at the time, is investigating and says it was one of a small number of recent similar incidents. But it refused to say whether the patient died, or to explain what the “catastrophic” consequences were. It says it is working to improve staff training to avoid similar incidents happening again. On Tuesday, Wales' health minister Eluned Morgan said the health board still had "a lot to do," before it could be taken out of special measures. A report to the committee said: “Further patient safety incidents have occurred in the health board related to the preparation and administration of oxygen using portable cylinders. “On review, the cylinder had not been prepared correctly, resulting in no flow of oxygen to the patient. “One incident had a catastrophic outcome and is under investigation.” Read full story Source: BBC News, 20 February 2024 -
News Article
‘Failure to act with candour’ over unsafe gas, report finds
Patient Safety Learning posted a news article in News
There was an “unacceptable delay” and “failure to act with candour” in how a trust responded to a serious risk from staff nitrous oxide exposure, an independent investigation has found. Mid and South Essex Foundation Trust found levels of nitrous oxide far above the workplace exposure limit at Basildon Hospital’s maternity unit during routine testing in 2021. However, staff were only notified and a serious incident declared more than a year later. The exposure related to a mixture of nitrous oxide and oxygen, commonly known as gas and air, used during births. While short-term exposure is considered safe, prolonged exposure to nitrous oxide could lead to potential health issues. Chief executive Matthew Hopkins has apologised, after a report by the Good Governance Institute said: “The inquiry found that there was an unacceptable delay in responding to and mitigating a serious risk that had been reported… As a result of this failure to act on a known risk, midwives and staff members on the maternity unit were exposed to unnecessary risk or potential harm from July 6 2021 to October 2022." Read full story (paywalled) HSJ, 14 February 2024 -
EventEnergy-based devices, lasers and diathermy are some of the most commonly used pieces of equipment in operating theatres today. Dangerous emissions can be produced that affect the respiratory systems of everyone in the operating theatre. This study day will look at the occupational hazards of exposure to surgical plume in the operating theatre, as well as the associated risks to the surgical team, patients and visitors. It will also highlight how to assess risk and mitigate against the dangers of surgical plume and how to implement changes. Topics Include: Electrosurgery/diathermy/laser. Anaesthetic airway fires. Laparoscopic surgery aerosolisation. Health and Safety and risk assessment. Surgical plume. Register
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News Article
Covid patients given early warning home oxygen monitors by paramedics
Patient Safety Learning posted a news article in News
Coronavirus patients who call an ambulance but are not yet sick enough to go to hospital are being given new home oxygen monitoring kits to help spot those who may deteriorate earlier. Across the Thames Valley region, thousands of patients will be given the kits which include a pulse oximeter device to monitor blood oxygen levels, a diary to track their symptoms and advice on what to do if they become sicker. South Central Ambulance Service Trust (SCAS) has become the first ambulance service in the country to launch the scheme after research showed a small drop in oxygen levels among some patients could be an early warning sign of serious complications. Patients with pneumonia and non-Covid lung conditions often experience shortness of breath before a drop in oxygen levels. But with coronavirus, patients can suffer what has been called ‘silent hypoxia’ where their oxygen levels can fall before the patient becomes breathless and calls for help. Read full story Source: The Independent, 2 February 2021 -
News ArticleOne of the mysteries of COVID-19 is why oxygen levels in the blood can drop to dangerously low levels without the patient noticing. It is known as "silent hypoxia" and as a result, patients have been arriving in hospital in far worse health than they realised and, in some cases, too late to treat effectively. But a potentially life-saving solution, in the form of a pulse oximeter, allows patients to monitor their oxygen levels at home, and costs about £20. They are being rolled out for high-risk Covid patients in the UK, and the doctor leading the scheme thinks everyone should consider buying one. A normal oxygen level in the blood is between 95% and 100%. "With Covid, we were admitting patients with oxygen levels in the 70s or low-or-middle 80s," said Dr Matt Inada-Kim, a consultant in acute medicine at Hampshire Hospitals. He told BBC Radio 4's Inside Health: "It was a really curious and scary presentation and really made us rethink what we were doing." Read full story Source: BBC News, 21 January 2021 See hub resource on the 'Covid Oximetry @home' project
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News Article
Trusts told to treat more COVID-19 patients at home
Patient Safety Learning posted a news article in News
Hospitals should ramp up their treatment of COVID-19 patients at home to free up more beds during the peak of the pandemic, under plans announced by NHS England/Improvement. All NHS trusts will receive up to 300 oximeters, which measure oxygen saturation levels and can be used to monitor COVID-19 patients in their own homes, rather than in hospital beds. NHSE has “recommended” that all areas of England “pursue immediate roll-out” given the “intense pressure on hospital beds right now”, according to a letter from medical director Steve Powis and two other national directors. Currently, nearly 60 trusts have COVID-19 patients in at least a third or more of their beds, and the total number of COVID-19 patients is peaking at around 37,000. There have been particular strains on hospital discharge, particularly of covid patients, whom many care homes are unable or unwilling to receive. The scheme, dubbed “covid virtual wards”, has been used at some trusts since the pandemic’s first wave. Read full story (paywalled) Source: HSJ, 19 January 2021 -
News ArticleThe Healthcare Safety Investigation Branch (HSIB) have launched a national investigation into the provision of piped oxygen gas supplies to hospitals. During the COVID-19 pandemic there has been an increased demand for oxygen gas on hospital wards, with more patients needing oxygen therapy. Insufficient oxygen supply to seriously ill patients can have very severe consequences, including death. The investigation is examining a major incident that took place at an acute hospital. Demands on their oxygen supply led to patients being diverted to other hospitals. In addition, patients were also transferred between clinical environments. As part of HSIB's final investigation report, they will make safety recommendations to the appropriate national bodies in order to improve patient safety. Read full story Source: HSIB, 15 January 2021
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News Article
Hospital's oxygen supply in 'critical' situation
Patient Safety Learning posted a news article in News
A hospital's oxygen supply has "reached a critical situation" due to rising numbers of COVID-19 infections. A document shared with the BBC showed Southend Hospital has had to reduce the amount it uses to treat patients. It said the target range for oxygen levels that should be in patients' blood had been cut from 92% to a baseline of 88-92%. Hospital managing director, Yvonne Blucher, said it was "working to manage" the situation. "We are experiencing high demand for oxygen because of rising numbers of inpatients with Covid-19 and we are working to manage this," she said. Read full story Source: BBC News, 11 January 2021 -
News ArticleHospitals across England could see oxygen supplies at worse levels this winter than at the peak of the first coronavirus wave – when some sites were forced to close to new admissions. An alert to NHS hospitals this week warned that because of the rise in admissions of COVID-19 patients, there is a risk of oxygen shortages. Trusts have been ordered to carry out daily checks on the amount of oxygen in the air on wards to reduce the risk of catastrophic fires or explosions. The problem is not because of a lack of oxygen but because pipes delivering the gas to wards will not be able to deliver the volume of gas needed by all patients. This can trigger a cut-off in supply and a catastrophic drop in pressure, meaning patients would be denied the oxygen they need to breathe. Read full story Source: The Independent, 20 November 2020
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News ArticleDemand for oxygen from COVID-19 patients recovering at home is set to place the NHS under strain, the health service has warned. NHS England has issued guidance to out-of-hospital health providers on the extra demands likely to be placed on them given the number of people recovering after a hospital stay with the coronavirus. It warns that the provision from its home oxygen services and community respiratory teams across the NHS is expected to be an issue as the scale of demand increases. Andrew Whittamore, a practising GP and clinical lead for the Asthma UK and British Lung Foundation partnership, said concerns about the potential for hospitals to be overwhelmed in the early part of the pandemic had led to community oxygen teams being primed to take on more patients – but he described that ramping up as “a short-term fix”. “We don’t know how long people are going to need oxygen or other services for,” he said. “There are definitely going to be extra patients added on to our community teams’ workloads.” The Taskforce for Lung Health – of which the British Lung Foundation is a member – has raised particular concerns about access to pulmonary rehabilitation. An education- and exercise-based treatment, which is proven to be more effective for lung patients than many drug-based treatments, and face-to-face classes have been suspended during the pandemic. It may be that such treatment would also be helpful for some patients recovering from COVID-19. Jackie Eagleton, policy officer at the British Lung Foundation, said there had been issues with access to pulmonary rehabilitation for a long time, but the need to offer this form of support to people with lung conditions “has never been more pressing than it is now”. Read full story Source: The Independent, 16 June 2020
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Content ArticleUK guidelines recommend that assessment and monitoring of breathless, unwell, or high risk patients with suspected COVID-19 should include pulse oximetry. Guidance published in January 2021 by the World Health Organization includes a provisional recommendation for “use of pulse oximetry monitoring at home as part of a package of care, including patient and provider education and appropriate follow-up. In this BMJ Practice article, Tricia Greenhalgh and colleagues discuss the remote management of COVID-19 using home pulse oximetry.
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Content Article
Guidance for: Prone positioning in adult critical care (2019)
Sam posted an article in Respiratory conditions
Guidance from the Faculty of Intensive Care Medicine and Intensive Care Society on prone positioning in adult critical care. It is hoped that the adoption of the guidance set out within this document will help improve safety and reduce complications associated with the prone positioning of mechanically ventilated patients. This document also hopes to standardise the approach to manging a cardiac arrest in the prone position, and has some guidance on prone ventilation in ECMO patients as well as considerations for performing bronchoscopy in the prone position. Assuming adequate staffing and equipment is available, the intervention of prone positioning involves very low costs and provided additional patient complications and long-term injuries to staff do not occur, would almost certainly be a cost-effective intervention. -
Content Article
HSIB: Oxygen issues during COVID-19 pandemic
Patient Safety Learning posted an article in HSSIB investigations
The Healthcare Safety Investigation Branch (HSIB) has been investigating piped oxygen gas supplies in hospitals and have produced an early interim bulletin to help trusts deal with oxygen flow issues in their organisations. The pandemic has placed massive pressure on the healthcare system, particularly when providing patients with enough oxygen to help treat the symptoms of COVID-19. HSIB's investigation so far indicates that trusts experiencing issues with oxygen demand have plenty of oxygen reserves [liquid oxygen]. However, the issue lies with a combination of the pipework/system used to deliver the oxygen and where patients needing the most oxygen are cared for along the oxygen supply network. HSIB therefore suggesting estates, pharmacy services and clinicians work closely together to map out the capabilities of their piped systems. They should consider spreading out patients with the highest need for oxygen more evenly, to help inform decisions about where patients may be safely cared for. The current pandemic has forced hospitals to reconfigure wards, and in so doing this has unbalanced the oxygen supply. Many hospitals work on a radial system, so the gas is pumped along the pipe network in one direction. When the system is balanced, anticipated levels of oxygen can be piped to everyone around the hospital. But, with increased and uneven demand on the pipe network - due to a group of COVID-19 patients, for example - oxygen supply levels may be reduced to other patient areas. -
Content Article'Covid Oximetry @home' describes an enhanced package of care for individuals with confirmed (or suspected) COVID-19 who are at risk for future deterioration. NHS England and Improvement wrote to all CCGs and trusts to encourage the development of local CO@H projects. The 'CO@h' package of care involves the remote monitoring of the patient's condition through providing regular contact with a local health care team who will reassess the individuals symptoms (including oxygen saturation levels). This close monitoring enables the individual to remain at their usual place of residence whilst allowing early signs of deterioration to be identified and escalated quickly and appropriately. This material has been designed primarily for use across the South East AHSN network by colleagues within the Wessex AHSN, Kent Surrey Sussex AHSN and Oxford AHSN regions. Colleagues from regions beyond the South East are also very welcome to make use of this toolkit in setting up their own local approaches to remote monitoring.
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Content Article
Patient safety poster: Air flow meters
PatientSafetyLearning Team posted an article in Improving patient safety
The unintentional connection of a patient requiring oxygen to an air flowmeter is listed by the NHS as a 'Never Event'. The patient safety notice poster below (and attached for better viewing) has been developed by Sandwell and West Birmingham NHS Trust, to help raise awareness among staff and prevent future errors. Do you use posters or infographics to improve patient safety locally? Why not get in touch by emailing [email protected], to share your examples more widely on the hub. -
Content ArticlePast research, some dating as far back as 1990 has highlighted a number of inaccuracies in readings when measuring oxygen levels in ethnic minorities. Especially now with the outbreak of coronavirus, further assessment is needed to ensure accurate measurements are being taken. The NHS Race and Health Observatory is now calling for further action and research alongside a rapid review includes a series of recommendations for national healthcare, regulatory and research bodies.
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Content ArticleA National Patient Safety Alert has been issued on the risk of harm from interruption of high flow nasal oxygen (HFNO) during transfer. This alert relates to the risk of harm caused by the interruption of HFNO to babies, children and adults in acute respiratory failure without hypercapnia during patient transfer. Some HFNO delivery devices have a transport mode, but most require mains power and will not deliver oxygen during transfer unless attached to a compatible uninterruptible power supply (UPS) device. The alert asks providers to add clear labels to HFNO delivery devices to make staff aware that even brief interruptions to mains power supply could lead to respiratory and cardiac arrest; and that HFNO in any emergency department or short stay unit must not be started without a plan for how to transfer the patient onwards. Where a UPS is used, action must be taken on the storage and maintenance of UPS devices to ensure they are ready for use and staff know where to locate them.
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Content ArticleToolkit to improve safety for mechanically ventilated patients helps hospitals in the US make care safer for mechanically ventilated patients in intensive care units (ICUs). ICU staff can use the toolkit to reduce complications for patients on ventilators.
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Content ArticleThe Healthcare Safety Investigation Branch (HSIB) launched an investigation following the referral of a case from an acute trust involving failure of oxygen delivery during a resuscitation. The case highlighted several issues related to the safe delivery of oxygen from portable systems.
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Content ArticleOperating theatre fires remain an uncommon but real safety risk for patients undergoing nearly all types of procedures, and despite ongoing safety initiatives, occur more commonly than wrong-site surgeries. One of the most compelling cases for safety improvement in the surgical setting is within this area. Combining the simple steps of operating theatre team education; improving lines of communication between surgeons, anaesthetists, and operating theatre nurses or practitioners; and the deliberate separation of the elements of the fire triangle can almost completely eliminate the incidence of surgical fires. In this brief review, Cowles Jr and Culp Jr hope that readers will be able to reduce the risk of surgical fires effectively by the application of the safety principles described. Key points Communication between members of the surgical team is an integral component of the prevention of surgical fires. Open delivery of 100% oxygen should be avoided if at all possible for surgery above the xiphoid process. Surgeons usually control the ignition sources, such as electrosurgical units and lasers. Operating theatre nurses or practitioners usually control the fuel sources, such as alcohol-based preparations and surgical drapes. The use of an ignition source in close proximity of an oxidiser-enriched environment creates a high risk for surgical fires.
