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What’s New in the Patient Safety World

July 2021

Unique Way to Rapidly Identify Oxygen Flow



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 National Health Service report on 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).


This system obviously can be very practical in patients being transported on portable oxygen. But it would also be useful for rapid identification of cases where oxygen hoses get disconnected from their sources for any reason.


It has another potential use as well. In our many columns on surgical fires, we’ve pointed out that almost all cases occur when a heat source, such as electrocautery, is used in the presence of active oxygen flow. To prevent such fires, it is essential that the anesthesiologist and surgeon coordinate to ensure that oxygen flow has been stopped prior to use of electrocautery (or any other heat source). Being able to visibly confirm there is no oxygen flow could be a very valuable patient safety tool in that setting.


Great concept!



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!

April 2009 “Nursing Companion to the BTS Oxygen Therapy Guidelines

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






NHS (UK National Health Service). Patient Safety Alert: Risk of death and severe harm from failure to obtain and continue flow from oxygen cylinders. January 9, 2018, updated December 9, 2019



St. Vincent’s Hospital (Melbourne, Australia) 2020; Video clip June 22, 2020






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