info@mgps-services.com


MGPS Services Ltd
The Stables
The Kennels
Siston Lane
Siston
Bristol
BS16 9LR

Tel: 0845 6524901
Fax: 0845 6524902
Email: info@mgps-services.com

Patient Safety Alert: Risk of death and severe harm from failure to obtain and continue flow from oxygen cylinders

Some patients need to be given additional oxygen1 as part of their treatment. Where there is no access to piped or concentrated oxygen, it is provided in cylinders, the design of which has changed over recent years. Cylinders with integral valves are now in common use and require several steps (typically removing a plastic cap, turning a valve and adjusting a dial) before oxygen starts to flow. To reduce the risk of fire2 valves must be closed when cylinders are not in use, and cylinders carried in special holders that can be out of the direct line of sight and hearing of staff caring for the patient.

An unintended consequence of these changes is that staff may believe oxygen is flowing when it is not, and/or may be unable to turn the oxygen flow on in an emergency.