A patient at St Mary’s Hospital was placed at risk of severe harm, or even death, when they were mistakenly connected to an airflow meter instead of oxygen.
The patient was being moved between wards when the incident happened last month.
Severe harm or death can occur if medical air is accidentally administered instead of oxygen.
No harm done
The patient was not harmed, as the mistake was immediately corrected by another member of staff who connected the oxygen tube.
The incident was classed as a ‘never event’ — a serious, entirely preventable, incident that should never have happened.
Medical air is used to help convert medication into an aerosol, and is widely used in the treatment of respiratory diseases, such as asthma.
Webster: Please staff felt able to report it
Director of nursing at the Isle of Wight NHS Trust, Alice Webster, welcomed the fact staff felt confident reporting such incidents to senior management.
She said:
“It is good we have changed our processes for reporting events.
“The patient suffered no harm and this issue is a national one, it’s not just confined to the Isle of Wight trust.”
Since 2013, the National Reporting and Learning System has reported two deaths, two patients severely harmed and more than 200 incidents with moderate to no harm from similar incidents across the UK.
Safety recommendations
The National Patient Safety Agency has recommended medical air units are covered with designated caps in areas where there is no need for medical air, that airflow meters are removed from terminal units and stored in an allocated place when not in use, and all airflow meters are fitted with a labelled, movable flap.
This is the first never event on the Isle of Wight in three years.
This article is from the BBC’s LDRS (Local Democracy Reporter Service) scheme, which OnTheWight is taking part in. Some alterations and additions may be been made by OnTheWight. Ed Image: © Used with the kind permission of Auntie P
