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Health Technical Ltd.
Medical Gas Specialists
Latest Medical Gas Alerts
Check back here regulary to keep up to date with all the latest medical gas alerts that have been issued.
Risk of death and severe harm from failure to obtain and continue flow from oxygen cylinders
A warning alert has been issued on the risk of death and severe harm from failure to obtain and continue flow from oxygen cylinders.
About this Alert
The design of oxygen cylinders has changed over recent years with the intention to make them safer to use. Cylinders with integral valves are now in common use and require several steps (typically removing a plastic cap, turning a valve and adjusting a dial) before oxygen starts to flow. To reduce the risk of fire valves must be closed when cylinders are not in use, and cylinders carried in special holders that can be out of the direct line of sight and hearing of staff caring for the patient.
An unintended consequence of these changes is that patient safety incidents have occurred where staff believed oxygen was flowing when it was not, and/or they have been unable to turn on the oxygen flow in an emergency.
This alert asks providers that use oxygen cylinders to determine if immediate local action is needed to reduce the risk of these incidents, and to ensure an action plan is underway to support staff to prevent them.
Different manufacturers and models of oxygen cylinders use different control designs. NHS Improvement and the Medicines and Healthcare products Regulatory Agency (MHRA) are supporting the distribution of training materials and resources for different manufacturers’ designs of oxygen cylinder via the Medication Safety Officer (MSO) and Medical Device Safety Officer (MDSO) networks.
The Health Safety Investigation Branch (HSIB) is also currently conducting an investigation
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into this safety issue.
June 2018 progress update
We have been made aware of a number of educational resources and design changes that have been made/produced to support the alert’s recommendations.
Oxygen cylinder manufacturer BOC, will be printing a message on the tamper evident seal advising users that the plastic pull tag must be pulled and the cap removed before the cylinder is used. They are also considering the possibility of putting a message on the plastic cover that protects the fir tree outlet that oxygen tubing is connected to. This message will provide basic instructions to connect the equipment to either the fir tree or Schrader outlet; open the cylinder valve (using the black hand wheel); and to select a flow (with the top flow selector) to administer the gas to the patient.
These modifications are being discussed with the MHRA. Further information can be accessed on the BOC website
A smart phone application is also available which calculates the estimated time remaining/gas available in a cylinder when the cylinder barcode is scanned and a flow rate is selected.
Most providers of oxygen cylinders have issued educational resources and step-by-step guides for how to safely and effectively use their oxygen cylinders. The majority have sent a notification to all NHS trusts on how to access e-learning platforms. Some also have free e-learning available on their websites, along with downloadable supporting user instructions and cylinder flow rate charts.
BOC have also produced an ‘Instructions for use’ YouTube video
At a local level, healthcare organisations have been able to link into their appointed Medication Safety Officer (MSO) and Medical Device Safety Officer (MDSO).
Following the issuing of the alert, a well-attended national MSO/MDSO WebEx was held. The WebEx signposted to resources from all manufacturers and relevant points from NHS estates guidance for medical gas pipeline systems (HTM 02-01)
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; highlighted guidance and resources showing oxygen cylinder use and flow rate/duration; and shared local initiatives that have been put in place in response to the alert. All resources are available through the MSO/MDSO Forum (access via MSO/MDSO network members).
Although MSO/MDSOs are predominantly based within an acute hospital, some are also based in primary care, mental health organisations and the community. Further details of who your organisation's MSO or MDSO is can be obtained at organisational level or by contacting the MHRA firstname.lastname@example.org
Reducing the risk of oxygen tubing being connected to air flowmeters
A stage three alert has been issued to support NHS providers that supply medical air using medical gas pipeline systems (MGPSs) to reduce the risk of harm from oxygen tubing being connected to air flowmeters.
About this alert
This alert has been issued to reduce the risk of harm caused from oxygen tubing being connected to air flowmeters. Severe harm or death can occur if medical air is accidentally administered to patients instead of oxygen.
Update to this alert: clarification for neonatal units and delivery suites
The basic principles outlined in this alert remain relevant to neonatal units and delivery units, air flowmeters should not be routinely left in wall outlets. However, we recognise that it will be appropriate in neonatal units and delivery suites to have both air and oxygen flowmeters left constantly in place as part of circuits connected to resuscitation equipment, such as ‘resuscitaires’ and ‘neopuffs’. Air flowmeters set up as part of circuits connected to resuscitation equipment would count as ‘active use’ for the purpose of declaring the actions required by the alert as complete.
Neonatal colleagues have emphasised that best practice would be to use wall or pendent/beam system ports and hoses to the equipment rather than flowmeters, and that a blender should be used to support mixing of air and oxygen supplies. Use of “Y” pieces to support gas mixing is not considered to be safe as the concentration of each gas is not likely to mix in a definable concentration/percentage.
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