This joint
National Patient Safety Alert has been issued by the NHS England National
Patient Safety Team, in collaboration with the Faculty of Intensive Care
Medicine, regarding the risk of harm from incorrectly assembled breathing
circuits lacking proper exhalation routes for patients receiving invasive or
non-invasive ventilatory support. Organisations caring for patients on invasive
and non-invasive breathing circuits are required to develop local guidance and
visual aids for circuit assembly, implement training on specific safety checks,
and establish clear communication processes.
All actions
must be completed within 6 months.