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Originator: National Patient Safety Alert - NHS England & NHS Improvement

Issue date: Originally issued on 01-Apr-2020 11:04:30. This version was issued on 01-Apr-2020 11:04:30

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

  • Other contacts
  • Independent Healthcare Providers (registered with CAS)
  • Clinical Commissioning Groups
  • NHS Foundation Trusts (England) - Medical Director
  • NHS Foundation Trusts (England) - Chief Executive
  • NHS Trusts (England) - Medical Director
  • Territorial CMOs in Northern Ireland, Scotland & Wales
  • NHS Trusts (England) - Chief Executive

Action category: Immediate Action

Title: Interruption of high flow nasal oxygen during transfer

Broadcast content:

This National Patient Safety Alert should be treated as a high priority as it may relate to care provided for Covid-19 patients. Please note deadline for actions to be completed is Wednesday 8 April 2020.

The alert relates to the risk of harm caused by the interruption of high flow nasal oxygen (HFNO) to babies, children and adults in acute respiratory failure without hypercapnia during patient transfer. Some HFNO delivery devices have a transport mode, but most require mains power and will not deliver oxygen during transfer unless attached to a compatible uninterruptible power supply (UPS) device.

Providers are asked to add clear labels to these devices to make staff aware that even brief interruptions to mains power supply could lead to respiratory and cardiac arrest; and that HFNO in any emergency department or short stay unit must not be started without a plan for how to transfer the patient onwards.

Where a UPS is used, action must be taken on the storage and maintenance of UPS devices to ensure they are ready for use and staff know where to locate them.

Alert reference: NatPSA/2020/002/NHSPS

Action underway deadline: 02-Apr-2020

Action complete deadline: 08-Apr-2020


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