Patient Safety Tip of the Week


October 6, 2009         Oxygen Safety: More Lessons from the UK



We’ve written several columns on issues related to oxygen therapy and many of the good recommendations have come from the UK. See our Patient Safety Tips of the Week for:


Last week the UK National Patient Safety Agency (NPSA) issued a Rapid Response Report on Oxygen Safety in Hospitals. This is issued as the rapid response report itself and separate briefings for physicians and for nurses, midwives and allied health professionals. But the most useful document is the one with supporting information.


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.


75 of the incidents involved prescribing or monitoring. Most involved inadequate monitoring of oxygen saturation but several also involved patients developing hypercapnia and respiratory acidosis.


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.


Miscellaneous cases included events such as fires from patients smoking while connected to oxygen.


They also reviewed the literature and investigation reports done at the local hospital level. We have previously discussed the need to treat oxygen as a medication and stressed the use of the new British Thoracic Society Guidelines for Emergency Oxygen Use in Adult Patients. They cite multiple audits that have been done showing poor compliance with the prescribing and monitoring of oxygen use recommended by those guidelines. Oxygen was often given without an order from a physician and when it was, it was often provided without prescription of specific delivery mode and flow rate or target O2 saturation.


Oxygen should be used only for patients who are hypoxemic and then should be formally prescribed. The prescription should specify a mode of administration and a target oxygen saturation rather than a specific dose. Nursing or respiratory therapy should be able to change the oxygen flow rates to achieve and maintain the target oxygen saturations. Special care should be taken when administering oxygen to those patients at risk for hypercapnia (eg. those with COPD, sleep apnea, morbid obesity, severe kyphoscoliosis or certain neuromuscular disorders, etc.), where lower oxygen saturation targets should be used.


The NPSA Rapid Response Report makes multiple sound recommendations:

  • All staff should be educated and oriented in the appropriate management of oxygen therapy.
  • Use of oxygen cylinders should be minimized (piped oxygen is preferred in most scenarios).
  • Where cylinders must be used, there should be robust systems in place reliable and adequate supplies.
  • The risks of confusing oxygen with compressed air or other medical gases must be assessed.
  • The BTS guidelines should be followed for all oxygen prescribing and monitoring.
  • Pulse oximetry should be available and used to monitor oxygen saturation in all areas where oxygen is used.
  • A “Medical Gas Committee” should be established to monitor and ensure safe and appropriate use of oxygen in all organizations. This should be a multidisciplinary group with representatives for all disciplines involved in oxygen use (including clinical personnel and respresentatives from pharmacy, patient transport, safety and risk management, biomedical engineering, supply, purchasing, and even a member of the Board). This group should be responsible for ensuring appropriate policies are in place and that adequate training be provided, monitor safety and availability of all oxygen equipment, audit the appropriateness of oxygen use and compliance with BTS guidelines, and review all incidents involving the use or misuse of oxygen.


They give many practical examples of how to avoid mixups between oxygen and other gases and how to avoid using cylinders that are empty or only partially filled. While they recommend appropriate labeling or color coding of wall gas outlets, it is interesting that they only briefly mention use of connectors that would make it impossible to connect oxygen to a source of gas other than oxygen. They stress separate storage for empty and full oxygen cylinders and good ways of labeling or otherwise identifying used or empty cylinders.


They provide a very good list of questions that staff should be able to answer after appropriate training. This includes very practical questions such as “Are staff checking the amount of oxygen in a cylinder before using it?” and they detail how staff would go about doing this.


One item we did not see in their otherwise extensive recommendations is the need to check all alarms on every ventilator prior to each use on patients. We previously described a case (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). The lesson learned in that case is that one should have a checklist-type routine for checking alarms immediately before a ventilator is used on a patient. And the checklist should be specific for the ventilator being used. It is not at all uncommon for a hospital to have multiple different models of ventilators and some may have alarms that others do not. Therefore, your protocol should include not only checking those alarms that are on all ventilators but also those that may be specific to the unit being used. Better yet, the design of new ventilators would automate such alarm checking prior to each use.


The Rapid Response Report also stresses the need for good planning when patients needing oxygen must be transported within hospitals or outside. In our Patient Safety Tips of the Week for April 8, 2008 “Oxygen as a Medication” and November 18, 2008 “Ticket to Ride: Checklist, Form, or Decision Scorecard?” we discussed in detail the risks involved with oxygen in patients during transports. The Ticket to Ride concept, in particular, is very useful in planning and implementing patient transports in a manner to ensure they don’t run out of oxygen and remain appropriately monitored throughout.


The Rapid Response Report also has links to good resources on use of pulse oximetry, fire and explosion hazards with oxygen, and tips on handling oxygen cylinders and their regulators. And, of course, the British Thoracic Society resource page on the guidelines for emergency oxygen use in adult patients provides a wealth of valuable resources, including sample policies, educational materials for staff, sample oxygen prescription forms, audit tools (for both the individual patient level and the medical unit level), and patient education materials.


All hospitals should have some initiative addressing high-risk medications in their organizations. If you consider oxygen as a medication, which you should be doing, it is one of the most high-risk medications you use in your organization. Making it a priority to monitor all aspects of oxygen usage and safety makes a lot of sense.





National Patient Safety Agency (UK). Rapid Response Report. Oxygen safety in hospitals. September 29, 2009


rapid response report


supporting information


briefing for doctors


briefing for nurses, midwives, and allied health professionals



British Thoracic Society. Guidelines for Emergency Oxygen Use in Adult Patients. Resource Page.



One Liners issue 67 - May 2009



Oxygen cylinders and their regulators - top tips leaflet.



Take care with oxygen. Fire and explosion hazards in the use of oxygen



General Practice Airways Group (GPIAG) opinion sheet on Pulse Oximetry in Primary Care.










Patient Safety Tip of the Week Archive


What’s New in the Patient Safety World Archive