Warning over errors with oxygen cylinders amid pressures on NHS

Pressures on the health service in England could have contributed to a number of patient safety incidents involving oxygen cylinders, according to an alert from the NHS.

It was issued after 120 incidents were linked to problems with the devices. The errors, which were recorded over the past 12 months, included staff giving patients empty cylinders or failing to switch over cylinders.

In some instances blunders “compromised” the delivery of oxygen to patients, which led to “serious deterioration and cardiac or respiratory arrest”, according to NHS England.

The alert states that extreme pressure on the health system, particularly when there are surges in respiratory illnesses such as flu and Covid-19, can lead to an increased use of oxygen cylinders where there is no access to medical gas pipeline systems. This might mean people who need oxygen being treated in a corridor or a side room not connected to the main supply system.

The surge in demand “increases the known risks associated with the use of oxygen gas cylinders”, the alert adds.

Other errors were recorded relating to “inappropriate” transportation of cylinders or devices not secured properly.

The document, issued to A&E departments and ambulance trusts, also states that “there is a need to conserve oxygen cylinder use to ensure a robust supply chain process”.

Trusts have been asked to ensure that risk assessments are done “in all areas where patients are being acutely cared for (either temporarily or permanently) without routine access to medical gas pipeline systems”.

The document says: “In the last 12 months (the NHS in England) 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.

“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. 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.”