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Originator: National Patient Safety Agency

Issue date: 29-Sep-2009 14:47:54

This alert has been issued to:
  • Care Trusts
  • Mental Health Trusts
  • Specialists Trusts
  • Learning Disabilities Trusts
  • Mental Health & Social Care Trusts
  • Ambulance Trusts
  • Primary Care Trusts
  • Mental Health & Learning Disabilities Trusts
  • Acute Trusts
  • Community Trusts

  • Other contacts
  • Independent Healthcare Providers (registered with CAS)
  • Ofsted recipients
  • Social Care Providers (registered with CAS)
  • Strategic Health Authorities
  • Special Health Authorities

Action category: Immediate Action

Title: Oxygen safety in hospitals

Broadcast content:

For IMMEDIATE ACTION by all hospitals (acute, community and mental health) in the NHS and the independent sector.

Oxygen is one of the most common medicines used in hospital settings. It is administered across a range of specialties and given by various healthcare professionals. Oxygen is indicated in many critical conditions and can save lives by preventing severe hypoxaemia. However, there is a potential for serious harm and even death if it is not administered and managed appropriately.

This RRR is directed to improve oxygen management in all hospital settings (while recognising the differences between large acute trusts and for instance mental health trusts, with different needs and risks). For primary care trusts, therefore, the requirements relate only to their responsibilities for care provided in community hospitals. As noted in the scope, the wider issues around oxygen use in the community (including home oxygen use) are not covered in this guidance.


The deadline for ACTION COMPLETE is no later than 29 March 2010.

A named senior lead, nominated by the Chief Executive, should ensure that:


Action 1: This RRR and the NPSA briefing sheets available (visit www.nrls.npsa.nhs.uk/alerts)  

                 highlighting actions to minimise risks of oxygen therapy are immediately made

                 available to all relevant staff.

Action 2: The use of oxygen cylinders is minimised and, where necessary, a business case for

      increased piped oxygen provision is developed in accordance with HTM 02-01 Part


Action 3: Where the use of oxygen cylinders is unavoidable (i.e. transfer and emergency

                situations or for mental health trusts), robust systems are in place to ensure reliable

                and adequate supplies, including checking and stocktaking of cylinders.

Action 4: The risks of confusing oxygen and medical compressed air are assessed and action

                plans developed (e.g. removing the medical air flow meter from the wall outlet when

                not in regular use).

Action 5: Oxygen is prescribed in all situations in accordance with BTS guidelines (but

                note these do not cover critical care or children under 16 years).  In an

                emergency, oxygen should always be given immediately and documented later.

Action 6: Pulse oximetry is available in all locations where oxygen is used.

Action 7: A multidisciplinary   group (such as a Medical Gas Committee) is responsible for

                reviewing oxygen related incidents, developing a local oxygen policy and a training


Webinar: Understanding and implementing the oxygen RRR


The NPSA will hold a webinar on Wednesday 7th October from 15.00 to 16.00 to assist with understanding and implementing this RRR. The webinar will be hosted by the NPSA and the panel includes clinical expertise from the British Thoracic Society and practical advice from a trust who have experience in developing safe oxygen sytems. We would like to invite all staff who are responsible for implementing the recommended actions or who have an interest in improving oxygen safety in their hospital. The purpose of the event is to discuss in more detail what the actions might mean to you and to share good practice with other trusts.


To register for the webinar:
1. Go to https://npsa.webex.com/npsa/j.php?ED=130326167&RG=1&UID=0
2. Register for the meeting.

You will receive a confirmation email with instructions for joining the meeting. There are limited places available so please register as soon as you can.

Further information

Supporting information on this Rapid Response Report, is available at: www.nrls.npsa.nhs.uk/alerts. Further queries should be directed to rrr@npsa.nhs.uk; Telephone 020 7927 9890.

Additional information: The NPSA has informed NHS Organisations, the Independent Sector, commissioners,
regulators, industry and relevant professional bodies.

Alert reference: NPSA/2009/RRR006

Action underway deadline: 27-Oct-2009

Action complete deadline: 29-Mar-2010

Gateway reference: 12455


Contact our helpdesk

Email: safetyalerts@mhra.gov.uk

Medicines and Healthcare products Regulatory Agency