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HSIB investigates portable oxygen system failure

The Healthcare Safety Investigation Branch (HSIB) has published an interim bulletin confirming its intention to continue to investigate the design and safe use of portable oxygen systems following a case where the oxygen supply to a patient failed even though the canister was full. 


In the Jan/Feb issue of HEFMA Pulse we reported on the Patient Safety Alert issued by NHS Improvement early in January, which required every organisation providing NHS funded care to carry out a four-stage action plan by February 20. This aimed to reduce the risk of life-threatening incidences involving failure of the oxygen system and to ensure an action plan is underway to support staff to prevent them.


The HSIB investigation will review the regulation and use of portable oxygen systems within the NHS in England. It will consider the system-wide influences on the design and safe use of such systems, including cylinders, manifolds, tubing and masks and question how positive changes and improvements to patient safety across the healthcare system may be achieved.


The case reported to HSIB happened within an acute setting, but oxygen systems similar to the one involved are widely used across the health service, including within ambulance services, GPs, mental health units, care homes and in the patient’s own home. The interim bulletin confirms that data gathered through the National Reporting and Learning System (NRLS) and the Strategic Executive Information System (STEIS) has highlighted a wide geographical spread with similar incidents occurring in several Trusts.


Furthermore, there is evidence to suggest that problems with the safe delivery of oxygen through portable systems are persistent, with multiple instances occurring in single Trusts.


The HSIB has identified three key safety issues during its initial review. These will form the basis of the ongoing investigation:


* Oxygen delivery via a portable system is a two-stage process (the user must open a valve and select the correct flow rate), compared to a one-stage process when oxygen is delivered via a hospital’s main supply through the wall


* Some portable oxygen systems do not provide a visual indication that the cylinder valve is open and do not provide a ‘live’ indication of the amount of oxygen remaining in the cylinder


* Some systems do not provide a visual indication that oxygen is flowing from the cylinder, through the tubing and to the patients. 


HSIB says it will continue to explore the identified safety issues and welcomes further information that may be relevant. 


The case reported


Sparking this investigation was the case of an 83-year old male patient who was found to be unresponsive. CPR was commenced and the patient’s breathing was supported using a bag-valve mask with a reservoir bag attached connected to a portable oxygen supply. 


The healthcare team believed oxygen was being delivered to the patient. It was 10 minutes later before it was recognised that the reservoir bag was not inflating between breaths. The team believed the cylinder was empty and replaced it but the patient remained unresponsive after further CPR and the decision was made to stop.


It was the following morning when the medical gases porter inspected the canister that was believed to be empty only to discover it was full.


The Medical Examiner concluded that the failure of the oxygen system was not responsible for the patient’s death because of his comorbidities and the fact he did not display any life signs when resuscitation started.