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Found 40 results
  1. News Article
    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
  2. News Article
    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
  3. News Article
    Hospital trusts must only remove gas and air on maternity wards as a “last resort”, NHS England has said. Several hospitals temporarily suspended the use of gas and air following concerns that midwives and staff are being exposed to too-high levels of gas over prolonged periods of time. Some pregnant women have posted on social media, saying the decisions have left them feeling anxious and worried about their pain relief options. Some NHS trusts have also come under fire for the way they communicated the message that gas and air would be suspended. In new guidance to trusts, NHS England said it had looked at the health impacts for staff of levels of nitrous oxide exceeding prescribed levels, “drawing upon relevant legislation and existing guidance on the safe management of gas and air in healthcare settings”. It said trusts must ensure they are compliant with legislation and national guidance on the use of gas, but must only remove it for women as a last resort and must tell them about other pain relief. “Where, following the meeting of the (medical gas) committee, there is concern that the trust is not compliant, then this should be formally reported by the trust to the NHS England regional operations centre for the attention of the regional chief midwife,” the guidance said. Read full story Source: The Independent, 3 March 2023
  4. News Article
    Scotland has become the first country in the world to stop its hospitals using the anaesthetic desflurane because of the threat it poses to the environment. NHS data suggests the gas, used to keep people unconscious during surgery, has a global warming potential 2,500 times greater than carbon dioxide. Banning it in Scotland - from its peak use in 2017 - would cut emissions equal to powering 1,700 homes a year. In the last few years, more than 40 hospital trusts in England and a number of hospitals in Wales have stopped using it. Dr Kenneth Barker, anaesthetist and clinical lead for Scotland's national green theatres programme, said he was shocked to find the anaesthetic drug he had used for more than a decade for many major and routine operations was so harmful to the environment. "I realised in 2017 that the amount of desflurane we used in a typical day's work as an anaesthetist resulted in emissions equivalent to me driving 670 miles that day," he said. "I decided to stop using it straight away and many fellow anaesthetists have got on board. "When you are faced with something as obvious as this and with the significance it has to the environment - I am very glad we have got to this stage." Read full story Source: BBC News, 3 March 2023
  5. News Article
    Nitrous oxide levels on Watford General Hospital's maternity suite far exceeded legal limits during peak periods, a BBC investigation has found. In February 2022, air monitoring showed levels of almost 5,000 parts per million (ppm) - 50 times what is safe. The hospital's trust said it had since installed machines to remove the gas. It was one of a number of nitrous oxide incidents reported by NHS trusts to the Health and Safety Executive (HSE), Freedom of Information data has shown. The HSE disclosed the details following a request for its notifications under the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013 (RIDDOR). There were 11 notifications to the HSE between August 2018 and December 2022 from seven NHS trusts and one private hospital in relation to nitrous oxide - almost all relating to maternity units. Monitoring has led to a string of NHS trusts suspending the use of Entonox - a mixture of nitrous oxide and air used to assist women in labour with pain relief. NHS bosses acknowledge there is "limited research on the occupational exposure to Entonox, and the long-term health risks this may pose", though at least one expert has played down the risk. But staff working in maternity units face uncertainty due to prolonged periods of time spent in affected areas, with particular concerns over Vitamin B deficiency due to exposure. Read full story Source: BBC News, 13 February 2023
  6. News Article
    A hospital has stopped using gas and air in its maternity unit to "protect our midwifery and medical team". The Princess Alexandra Hospital in Harlow, Essex, said the decision followed tests on nitrous oxide levels. It said it would temporarily suspend the use of Entonox while additional safety equipment was installed. Giuseppe Labriola, director of midwifery, said: "There is no risk to mothers, birthing people, their partners and babies." Other hospitals have previously temporarily suspended the use of gas and air in recent months including Basildon and Ipswich. Read full story Source: BBC News, 22 January 2023
  7. News Article
    Staff at a maternity unit were exposed to almost 30 times the legal workplace exposure limit for nitrous oxide, documents have shown. Testing at Basildon Hospital revealed the levels more than 16 months before colleagues were informed. The Royal College of Midwives said its members there were considering legal action. Routine testing of the maternity suite in June 2021 revealed nine staff members had been exposed to excess nitrous oxide levels during the course of their shifts. Three had readings of more than 1,000 parts per million (ppm) of the gas, while a fourth recorded almost 3,000. The Workplace Exposure Limit is set at 100ppm. Trust management apologised after failing to notify staff at the unit until October 2022. A briefing seen by the BBC stated the issue was logged on the risk register, but "there has not been proper oversight of the problem and staff have not been informed". One person familiar with the situation, who did not want to be identified, said: "We had an email sent out that said 'emergency maternity staff briefing' and there was a Teams meeting. "The Teams meeting was very, very difficult to listen to. It was very emotive. People were angry understandably, but I feel like the executive who were on the call didn't handle it very well." Read full story Source: BBC News, 16 January 2023
  8. News Article
    Some hospitals are suspending supplies of gas and air, after it was found to pose health risks to midwives. What can be done to ensure pregnant women still get the help they need? When Leigh Milner was expecting her first baby, she knew exactly how she wanted her labour to go. Her birth plan included an epidural for the pain and she was hoping, she says ruefully, for “all the drugs”. But that is not how things worked out. Milner, 33, a BBC presenter, ended up giving birth to Theo at Princess Alexandra hospital in Harlow last month with nothing but paracetamol for pain relief, in what she calls a positively “Victorian” experience. “I kept begging over and over again – ‘I need something for pain relief’ – and the only thing they could give me was paracetamol because they didn’t have gas and air. I was quite frightened, I didn’t know what else to do,” says Milner. "Birth is painful, but it shouldn’t be traumatic.” Read full story Source: The Guardian, 16 March 2023
  9. Content Article
    During periods of extreme pressure, often exacerbated by a surge in respiratory conditions, demand on supplies of oxygen cylinders, especially the smaller sizes, increases in the NHS due to the need to provide essential oxygen treatment in areas without access to medical gas pipeline systems. This surge in demand increases the known risks associated with the use of oxygen gas cylinders, and introduces new risks, across three main areas: patient safety fire safety physical safety A search of incidents reported to the of the National Reporting and Learning System (NRLS) and Learn from Patient Safety Events (LFPSE) service in the last 12 months identified 120 patient safety incidents, including those with these themes: cylinder empty at point of use cylinder not switched on cylinders inappropriately transported cylinders inappropriately secured Some of these reports described compromised oxygen delivery to the patient, leading to serious deterioration and cardiac or respiratory arrest. In addition there is a need to conserve oxygen cylinder use to ensure a robust supply chain process. As a result of current pressures on the NHS, NHS England issued providers with a summary of best practice guidance on the ‘Safe use of oxygen cylinders’ on Friday 06 January 2023 to support providers to optimise and maintain the safe use of oxygen cylinders. This guidance was issued via the Patient Safety Specialist and Emergency Preparedness, Resilience and Response (EPRR) networks. Actions To be completed as soon as possible, and not later than 20 January 2023. 1.  The chair of acute trust medical gas committee, working with key clinical/non-clinical colleagues including the local ambulance trust, should review the NHS England ‘Safe use of oxygen cylinders’ best practice guidance and ensure a risk assessment is undertaken in all areas where patients are being acutely cared for (either temporarily or permanently) without routine access to medical gas pipeline systems.  Risk assessment should pay particular attention to: avoiding unnecessary use of cylinder oxygen and excessive flow rates by ensuring oxygen treatment is optimised to recommended target saturation ranges. ensuring safe use of oxygen cylinders by clinical staff including; - safe activation of oxygen flow - initial and ongoing checks of flow to patient - initial and ongoing checks of amount of oxygen left in the cylinder - especially during transfer or whilst undergoing diagnostic tests. fire safety, including: - appropriate ventilation (both in physical environments and in ambulances),  safe storage of cylinders physical safety, including: - awareness of manual handling requirements - safe transportation of cylinders using appropriate equipment - safe storage of cylinders. 2. Once the risk assessments have been undertaken, convene the acute trust medical gas committee as soon as possible to review the findings of the risk assessments and formalise an action plan. Ensuring that the committee has executive director representation and ambulance trust input.
  10. Content Article
    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.
  11. News Article
    Demand 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
  12. Content Article
    UK 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.
  13. Content Article
    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 content@patientsafetylearning.org, to share your examples more widely on the hub. 
  14. Content Article
    Past 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.
  15. Content Article
    The Chartered Institute of Ergonomics and Human Factors (CIEHF) has launched an oxygen safety campaign aimed at people working at patient bedsides within hospitals. They have consulted with clinicians, fire safety experts and a wide range of allied professional bodies to design the campaign, which has been launched in response to the anticipated national surge in hospital patients as a result of the Omicron variant. Inevitably, the use of oxygen will be very high and issues such as oxygen leakage can cause major fire risks.
  16. Content Article
    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.
  17. Event
    Energy-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
  18. News Article
    Hospitals 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
  19. News Article
    Devices which measure blood oxygen levels could be giving “seriously misleading” results for Black and minority ethnic people, possibly contributing to increased Covid-19 mortality, experts have warned. Pulse oximeters attach a clip-like device to a person’s finger, toe or earlobe and send a beam of infrared light to measure oxygen levels in the blood. The resulting reading can be used to monitor oxygen levels of people with a variety of conditions, including by people at home with coronavirus, and to assess patients in hospital. At the moment, coronavirus patients who call an ambulance but are not yet deemed sick enough to go to hospital are being given new home oxygen monitoring kits to help spot those who may deteriorate earlier, and over 300,000 oximeters have been sent out by NHS England. But a new paper cites a “growing body of evidence” that pulse oximetry is less accurate in darker skinned patients. This could be contributing to health inequalities such as the increased COVID-19 mortality rates of ethnic minority patients, according to a review conducted for the NHS Race and Health Observatory. It is now calling for the Medicines and Healthcare products Regulatory Agency (MHRA) to urgently review pulse oximetry products for ethnic minority people used in hospitals and by the wider public. Read full story Source: The Independent, 27 March 2021
  20. News Article
    Doctors and nurses were absent from crucial meetings about oxygen supplies to hospital wards in the run up to the coronavirus crisis, a safety watchdog has warned. At one hospital trust, which was forced to declare a major incident during the second wave of the crisis, doctors had not attended the hospital’s medical gas committee (MGC) since 2014. The Healthcare Safety Investigation Branch (HSIB) said it had discovered a similar lack of input at other NHS trusts and also warned that none of the urgent alerts and guidance from NHS England ahead of the Covid surge had been discussed at the committee. HSIB has launched an investigation into the failure of oxygen piping systems during the Covid surge after a number of hospitals were forced to declare major incidents and divert patients to other hospitals. Read full story Source: The Independent, 24 March 2021
  21. News Article
    There was a "gross failure in basic care" which led to a baby being starved of oxygen during birth, a coroner said. Zak Ezra Carter died at the Royal Gwent Hospital, Newport, two days after being born in July 2018 at Ystrad Fawr Hospital in Caerphilly county. Gwent coroner Caroline Saunders said the monitoring of Zak and his mother Adele Thomas fell "well below the standards expected". She said she was reassured the health board had taken steps to improve care. Ms Thomas told the Newport hearing she felt "scared" and staff "didn't care" when she arrived to give birth on 20 July 2018. In a statement to the inquest she described being turned away from the centre after going into labour on three occasions, before being admitted on the fourth. Ms Thomas said she was initially offered paracetamol as pain relief at the midwife-led centre. She described "a lot of arguing between nurses", one of whom was "bolshie and rude and rough handled me", adding the midwives "did not appear to be in any rush". When Zak was born, he was described as being "white and pale" and without a heartbeat. He did not cry and was taken away to a room for resuscitation. Zak was transferred to the Royal Gwent Hospital where he died two days later. During the first stage of labour, Prof Sanders said "everything was progressing at a normal healthy rate and the fetal heart rate was recorded as completely normal". But she said it was "highly unusual" for the heart rate to not be documented contemporaneously, and the midwives had not been able to explain why they had not done so. Recording a narrative conclusion, Ms Saunders said the monitoring of Ms Thomas and her baby had "fallen well below the standards expected", leading to a "gross failure in basic care" of them in the later stages of labour. Read full story Source: BBC News, 18 March 2021
  22. News Article
    Shortages of oxygen are endangering the lives of more than half a million COVID-19 patients every day in the world’s poorest nations, new research has shown. Despite being vital for the effective treatment of people admitted to hospital with coronavirus, sustained access to oxygen has proven difficult in low- and middle-income countries (LMICs) due to cost, infrastructure and logistical barriers. According to Unitaid, a global health agency, more than half a million people in LMICs currently need 1.1 million cylinders of oxygen per day, with 25 countries currently reporting surges in demand, the majority in Africa. Supplies of oxygen were already constrained prior to COVID-19 and have been exacerbated by the pandemic, Unitaid says. Read full story Source: The Independent, 25 February 2021
  23. News Article
    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
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