A National Patient Safety Alert has been issued by NHS England 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.
Air flowmeters attached to piped medical air outlets are primarily used to drive the administration of nebulised medication; typically for short periods to manage respiratory conditions. Most other uses of piped medical air do not require an air flowmeter.
Because of 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, the alert says.
The 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.
A previous alert and additional communications have sought to minimise the use of air flowmeters by encouraging their replacement with compressors or ultrasonic nebulisers, alongside additional risk reduction methods if air flowmeters remained in use. A recent survey of Medical Device Safety Officers indicated that many hospitals no longer use air flowmeters and others are part way through eliminating their use.
Despite the measures outlined above, 108 ‘Never Events’ describing unintentional connections were reported in a recent three-year period. More than a third of incidents occurred in emergency departments. Consequences included respiratory arrest, cardiac arrest, collapse (requiring intensive therapy unit admission and ventilation) and nine incidents of incorrect connection when responding to cardiac arrest, which have affected the chance of successful resuscitation; six patients subsequently died.
This article originally appeared on Univadis, part of the Medscape Professional Network.
