Source · HSSIB Patient Safety Investigation
Piped supply of medical air and oxygen
Published 15 March 2021
Launched 20 November 2018
Published
HSIB Legacy
Never events
This investigation focuses on the design and implementation of patient safety alerts. It follows a reference event where an 85-year old woman was connected to the piped medical air supply, instead of the oxygen supply, whilst she was receiving hospital treatment after a fall at home.
Summary
1 recommendation
1 of 1 responded
Safety Recommendations
Recommendation 1
National Patient Safety Alert Committee
The National Patient Safety Alert Committee should set standards for all issuers of patient safety alerts that require an assessment for unintended consequences, the effectiveness of barriers in the alert, and the advice the alert issuers give providers on implementation and ongoing monitoring.
The National Patient Safety Alert Committee confirmed its existing standards, active since May 2019, already incorporate requirements for assessing unintended consequences, alert effectiveness, and providing implementation advice for complex alerts.
Response received 14 May 2019
As chair of the National Patient Safety Alert Committee, whose members include all arms-length bodies and teams who issue national safety guidance in the form of alerts, I [Dr Aidan Fowler] welcome the recommendation from HSIB. I can confirm that the standards that the National Patient Safety Alert Committee (NaPSAC) agreed in 2018 include, amongst other criteria, that: “There is a procedure for the development of actions required in the National Patient Safety Alert that includes: an assessment of the actions for potential unintended consequences is carried out [and] an assessment of the likely effectiveness of the actions in reducing future harm is carried out.” These standards also include a requirement that “The system [of each alert-issuing body] sets out what types of supporting materials should be provided by the alert issuing team/body for complex National Patient Safety Alerts.” This requirement encompasses materials to support providers with implementation and ongoing monitoring where this is required; we would not expect this support to be required for some National Patient Safety Alerts that are straightforward (for example, some types of drug or device recall) or National Patient Safety Alerts that contain systemic actions that once taken eliminate the need for ongoing monitoring. A key aspect of the work of NaPSAC is the role of CQC [Care Quality Commission] in inspecting compliance with National Patient Safety Alerts and where appropriate using its regulatory powers. The NaPSAC standards became active on 13 May 2019 and the first alert-issuing body is currently preparing its application to become a credentialled issuer of National Patient Safety Alerts. Progress will be publicly reported on the National Patient Safety Alert Committee webpages . Response received on 14 May 2019.