weLearn Wednesdays – positive patient identification and airflow meters

March 9, 2022

It is vital that we learn from experience: Incident/near misses, complaints, litigation, claims and audits and lessons learned are widely shared.

Learning 1: Never events (including near misses) have occurred when the wrong patient has/nearly received the wrong surgery.

Never read the patients details out to the patient and allow them to positively agree.
Complete your WHO checklist and be audit compliant

Ensure you have read and understood the Trust policy relating to patient identification here: Positive Patient Identification Policy

Learning 2: Never events have occurred of patients unintentionally connected to air instead of oxygen.

These incidents have happened in quick succession, the sixth happening despite all flow meters asking to be removed. No patients came to harm as all errors were noticed and rectified immediately.

Patient Safety Notice
Air Flow Meters

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

The national safety alert regarding airflow meters can be found here: National Safety Alert