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In our October 6, 2009 Patient Safety Tip of the Week “Oxygen Safety: More Lessons from the UK” we reported on a UK National Patient Safety Agency (NPSA) Rapid Response Report on Oxygen Safety in Hospitals. The NPSA alert followed reports of 281 incidents involving oxygen over a 5-year period, 9 of which caused patient deaths and another 35 of which may have contributed to patient deaths.
103 of the incidents involved equipment, including empty oxygen cylinders, missing or faulty equipment, inaccessibility of equipment, or user errors. A large number of these incidents occurred during patient transports or transfers. We’ve previously noted that some studies have shown over 50% of all inhospital transports have been complicated by oxygen supplies running out and encouraged use of tools such as “Ticket to Ride” to help avoid such events.
In 54 of the incidents, oxygen was not appropriately administered. This included cases where compressed air was mistakenly given to patients, cases where oxygen sources were disconnected, and cases where oxygen was given at incorrect flow rates. Again, some of these occurred during transport of patients within the hospital, often by nonclinical personnel.
Then, in our February 2018 What's New in the Patient Safety World column “Oxygen Cylinders Back in the News” we discussed a 2018 UK over 400 incidents involving incorrect operation of oxygen cylinder controls, including 6 patient deaths (NHS 2019). Incidents involved portable oxygen cylinders of all sizes on trolleys, wheelchairs, resuscitation trolleys and neonatal resuscitaires, and larger cylinders in hospital areas without piped oxygen. The problem was related to the design of portable oxygen cylinder controls. “Staff appeared to assume the same single step to start piped oxygen flowing (turning the flowmeter dial) also applies to cylinders. They also appeared confused by aspects of the cylinder’s design: no clear indicator on the valve showing the open and closed positions, and the plastic cap hiding controls. The green indicator showing a full cylinder appeared to be misinterpreted as an indicator of active flow. When the flow rate dial is operated on cylinders that have previously been used, but not vented before next use, a ‘hiss’ of flowing oxygen can be heard for a few seconds even with the valve closed. This can reinforce a member of staff’s belief that they have turned the flow on. Reinforcement of the need for oxygen to be considered a prescribed medication seemed in some cases to have been misinterpreted as meaning only clinical professionals could check or prepare cylinders for use.”
We’ve also noted our own experiences with lack of oxygen flow. We previously described a near-miss (see our March 5, 2007 Patient Safety Tip of the Week “Disabled Alarms”) in which an oxygen blender alarm on a ventilator failed to alert staff to disconnection of the oxygen source because a piece of tape had been placed over the blender alarm (probably during maintenance). Problems with a pulse oximeter also failed to alert staff to the lack of oxygen flow in that case.
So, wouldn’t it be useful to have a way to rapidly identify lack of oxygen flow? An Australian anesthesiologist came up with a practical solution to the problem. Dr. Matthew Matusik came up with the solution after a near-miss in which a patient being transported from the OR to the PACU temporarily had no oxygen flow because of a problem related to the oxygen cylinder system being used. He developed a face mask with a flow indicator that provides a clear visual cue that oxygen is flowing to a patient. If oxygen is flowing to the patient, a bright orange indicator is visible (see the St. Vincent’s Hospital video 2020
Some of our prior columns on issues related to oxygen:
April 8, 2008 “Oxygen as a Medication”
January 27, 2009 “Oxygen Therapy: Everything You Wanted to Know and More!”
October 6, 2009 “Oxygen Safety: More Lessons from the UK”
July 2010 “Cochrane Review: Oxygen in MI”
December 6, 2011 “Why You Need to Beware of Oxygen Therapy”
February 2012 “More Evidence of Harm from Oxygen”
March 2014 “Another Strike Against Hyperoxia”
June 17, 2014 “SO2S Confirms Routine O2 of No Benefit in Stroke”
December 2014 “Oxygen Should Be AVOIDed”
August 11, 2015 “New Oxygen Guidelines: Thoracic Society of Australia and NZ”
November 2016 “Oxygen Tank Monitoring”
November 2016 “More on Safer Use of Oxygen”
October 2017 “End of the Oxygen in MI and Stroke Debate?”
February 2018 “Oxygen Cylinders Back in the News”
June 2018 “Too Much Oxygen”
2019Patient Safety Alert: Risk of death and severe harm from failure to obtain and continue flow from oxygen cylinders. January 9, 2018, updated December 9,
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