A National Patient Safety Alert has been issued on the risk for harm from interruption of high flow nasal oxygen (HFNO) during transfer within a hospital.
Extrapolation from a sample of no- or low-harm incidents from the National Reporting and Learning System indicated that, between 1 October 2017 and 6 November 2019, there were about 150 safety incidents related to the transfer a patient on HFNO.
Four deaths appeared to be directly linked to the transfer. One patient was known to be within hours/days of death and three were critically ill with unknown chances of survival, but the timing and cause of death appeared directly linked to the HFNO interruption.
The review suggested some staff may assume devices have an internal battery. Furthermore, some appeared not to realise how rapidly a patient can deteriorate with even brief interruption of HFNO. There also appeared to be a misconception that less intensive methods of oxygen delivery are an adequate substitute during transfer.
Consequently, it is recommended that labels are placed on HFNO delivery devices to make staff aware that even brief interruptions to mains power supply could lead to respiratory and cardiac arrest. HFNO must not be started in an emergency department or short stay unit without a plan for how to transfer the patient onwards.
Where an uninterruptible power supply device is used, action must be taken on the storage and maintenance of these devices to ensure they are ready for use and staff know where to locate them.
