Leeds hospital bosses act to prevent oxygen blunder

The mistake has been reported 57 times at hospitals in England since it was classed as a “never event’ by health service bosses in February 2018, according to NHS incident reports.

That included three times at Leeds Teaching Hospitals NHS Trust, where bosses have since removed airflow points on some wards to protect against it happening again.

Acting chief executive Yvette Oade said: “Thankfully none of the incidents caused harm to the patients involved and no further incidents have occurred since May 2018.

“We removed the air supply from areas where it isn’t needed and added an additional safety feature to bedside medical gas supply systems to prevent inadvertent administration of medical air.”

Trusts around the country were told to remove airflow metres which were wrongly used to administer gas to patients,

But some misinterpreted the guidance, said a report by the Healthcare Safety Investigation Branch (HSIB). The HSIB investigation found some trusts failed to implement the recommendations, sometimes due to the cost of changing equipment.

Dr Oade said: “Our trust-wide Medical Gases Group reviewed the guidance, communicating the new never event status to clinical staff and sharing updates to ensure staff have the most up to date knowledge in how to administer medical gases appropriately.”

Oxygen is used to treat patients during medical emergencies to boost low blood oxygen levels and reduce breathlessness.

Medical air is used in nebulisers, which convert medication into gas, and in ventilators for patients who are sensitive to oxygen.