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Originator: NHS Improvement

From: James Nicholls

Issue date: 18-Dec-2018 11:00:11

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

  • Other contacts
  • Independent Healthcare Providers (registered with CAS)
  • Clinical Commissioning Groups
  • Social Care Providers (registered with CAS)
  • Special Health Authorities

Action category: Immediate Action

Title: Risk of harm from inappropriate placement of pulse oximeter probes

Broadcast content:

Measurement of oxygen saturation, using a pulse oximeter probe, is routinely undertaken as part of patients’ vital signs during diagnosis and ongoing monitoring. Oximeter probes can be single or multiple use and are designed to attach to specific parts of the body. Adult oximeter probes can be attached to either a finger or an ear, but are not interchangeable between these sites, whilst probes for babies and children need to be selected according to the patient’s weight. Inappropriate placement of oximeters can lead to an inaccurate reading putting the patient at risk of harm. 

Additional information: NHS regional teams, please cascade this alert to GPs. Can you please include the following in your covering email to general practice: 'This alert has actions for general practice who will need access to appropriate oximeter probes for adults, and babies and children, to ensure accuracy of readings.'

Alert reference: NHS/PSA/W/2018/009

Action underway deadline: 21-Dec-2018

Action complete deadline: 18-Jun-2019


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Email: safetyalerts@mhra.gov.uk

Medicines and Healthcare products Regulatory Agency