A National Patient Safety Alert has been issued asking all providers that use piped medical air to eliminate the risk of inadvertently connecting patients to medical air via a flowmeter instead of oxygen.
Due to the proximity of the piped medical air and oxygen outlets at the bedside, and the similarity in design of flowmeters, there is a significant risk when using air flowmeters that patients may be inadvertently connected to medical air instead of oxygen.
A previous alert and other communications have sought to minimise the use of flowmeters by encouraging their replacement with compressor or ultrasonic nebulisers, alongside additional risk reduction methods if air flowmeters remained in use. As a result, many hospitals no longer use air flowmeters and many more are in the process of eliminating their use.
Where air flowmeters are still in use, the risk of inadvertent connection remains. The NHS England Never Events data publication reported 108 Never Events in the three years between April 1, 2018 and March 31, 2021. More than one third of these incidents occurred in emergency departments, with consequences including respiratory arrest, cardiac arrest, collapse requiring ITU admission and ventilation, as well as nine incidents of incorrect connection when responding to cardiac arrest which will have impacted on the chance of successful resuscitation – six patients subsequently died.
This alert asks providers to purchase alternative devices that do not require medical air to be delivered via an air flowmeter. Following this, all medical air flowmeters except those tethered to equipment for niche use should be discarded, and all medical air outlets no longer required should be reversibly capped off.
