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National Patient Safety Agency

NPSA advising hospitals to follow new oxygen safety guidance



New guidance, produced by the National Patient Safety Agency (NPSA) and NHS organisations across England and Wales, has been released aimed at ensuring safer systems are in place to treat patients needing oxygen.


The alert to all NHS acute, community and mental health organisations, as well as the independent sector, follows reports received by the NPSA of 281 serious incidents between December 2004 and June this year. 


Of these incidents, poor oxygen management appears to have caused nine deaths and may have contributed to a further 35 deaths.


Common incidents that were highlighted within the reports include:


  • Failure or wrongly prescribed dosage;
  • Failure to monitor oxygen blood concentration;
  • Confusion of oxygen with compressed air;
  • Empty cylinders, faulty and missing equipment.


Dr Kevin Cleary, NPSA’s Medical Director, said: “Oxygen is one of the most common medicines given to thousands of patients each day across England and Wales and most is given safely.  However because of a lack of awareness, oxygen is often given without any prescription and patients are attached to oxygen tubing with no documentation of their medicine on their treatment chart.


“We have received reports of preventable incidents where oxygen cylinders were empty or patients were harmed when oxygen and air outlets were confused.   Our recommended actions should make systems safer by reducing reliance on cylinders and reminding staff of the need to follow clinical guidelines in safe prescribing, administration and monitoring of patients on oxygen.”


This latest advice has been released after it was produced following joint working between the NPSA and NHS organisations across England.  It is intended to ensure:


  • staff follow clinical guidelines on safe prescribing of oxygen and monitoring of patients;
  • the use of oxygen cylinders is minimised in favour of safer (and cheaper) piped oxygen, where appropriate;
  • action is taken to reduce risks of confusion between air and oxygen;
  • multidisciplinary groups are tasked with developing safer systems for oxygen across hospitals.


Dr Cleary added: “Whilst the incidents reported to us are tragic we hope that our actions will ensure that lessons have been learned to prevent further harm to patients.


“There are many good practice examples across the NHS where oxygen is being effectively managed by clinicians – from which we can all learn.”


One NHS organisation that has made huge changes in the way it manages oxygen use over recent years is Colchester University Hospital NHS Foundation Trust.


Biomedical Engineer Steve Connew said: “We have taken this matter extremely seriously as poor working practices can have an adverse effect on the health and safety of patients and staff as well as wasting valuable resources.

“Over the past year, we have held over 130 safe use and handling medical gas courses to staff who are involved in providing oxygen to patients.  They range from porters to frontline clinicians, and we’ve noticed a significant reduction in the amount of oxygen wastage and cylinder stockholding.  We’ve asked staff to ensure flow meters and cylinder valves are turned off when not in use.


“In addition, with our clinical staff, we have rationalised cylinders on wards and have issued guidance to all staff on appropriately sized cylinders.  This has dramatically led to a reduction in cost, wastage and harm.”


Professor Mike Morgan, Chair of the British Thoracic Society (BTS) said the guidance is very timely:


“The British Thoracic Society is currently supporting the implementation of our recent UK Guideline for Emergency Oxygen use in adults, which has been endorsed by 21 other royal colleges and societies. The guidance says that oxygen should be prescribed like any other drug (except in serious emergencies) and its use should be monitored using pulse oximeters which are now widely available.”


Professor Morgan added: “The goal of oxygen treatment is to achieve safe oxygen saturation (94 – 98 per cent) for most acutely ill people.  However oxygen therapy may have significant risks for vulnerable respiratory patients where a lower target saturation (88 – 92 per cent) is required.  The BTS has appointed “Oxygen Champions” in most acute UK hospitals to help introduce the guidelines to improve oxygen use, enhance patient safety and audit usage.”


To view the guidance, please visit: www.npsa.nhs.uk/nrls/alerts-and-directives/rapidrr/




Notes to Editors:


Media enquires to the NPSA Press Office:


The National Patient Safety Agency is an Arm’s Length Body of the Department of Health. It encompasses three divisions; the National Research Ethics Service, the National Reporting and Learning Service and the National Clinical Assessment Service. Each has its own sphere of expertise to improve patient outcomes. The NPSA’s vision is to lead and contribute to improved, safe patient care by informing, supporting and influencing healthcare individuals and organisations. For more information visit: www.npsa.nhs.uk.