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

Issue date: 16-Jun-2021 09:29:22

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 Trusts
  • Acute Trusts
  • Community Trusts

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

Action category: Action

Title: Eliminating the risk of inadvertent connection to medical air via a flowmeter

Broadcast content:

Due to the proximity of the piped medical air and oxygen outlets at the bedside, and the similarity in design of flowmeters, there is a significant risk when using air flowmeters that patients may be inadvertently connected to medical air instead of oxygen.

The alert asks providers to purchase alternative devices that do not require medical air to be delivered via an air flowmeter. Following this, all medical air flowmeters except those tethered to equipment for niche use should be discarded, and all medical air outlets no longer required should be reversibly capped off.

Additional information: This alert is not relevant to Primary Care.

Alert reference: NatPSA/2021/003/NHSPS

Action underway deadline: 18-Jun-2021

Action complete deadline: 16-Nov-2021


Contact our helpdesk

Email: safetyalerts@mhra.gov.uk

Medicines and Healthcare products Regulatory Agency