Patient safety notice: Air flow meter use ‘never events’

July 21, 2021

You may be aware that some incidents that happen to patients are called ‘never events’ as they have been identified as events that should never happen, largely because there are mechanisms or systems in place to prevent them.

Recently we have had four ‘never events’ all relating to the same issue – patients being unintentionally connected to air instead of oxygen. There have been a total of 108 similar incidents in the past three years across the NHS, enough to make NHS England issue a patient safety alert.

Whilst we review our long-term actions to prevent inadvertent use of medical air, we have issued a learning alert to remind colleagues of our current practice.

• Ensure medical air flowmeters are removed from terminal units (wall outlets) and stored in an allocated locked place when not in use.
• Ensure unused air outlets are covered by a removable spigot (until permanent ones are sourced)
• Ensure when air flowmeters are in use they are fitted with a labelled, movable flap

Patient safety notice – air flow meters

We ask all clinical colleagues to bring this safety issue to the attention of everyone and share the above patient safety notice relating to air flow meters.