- HSIB highlights finance and PFI contracts as a “systemic barrier” to responding to safety alerts
- Investigation follows continued errors in connecting patients to piped air instead of oxygen
- NHS trusts misinterpreted patient safety alert recommendations as optional
Private finance initiative contracts and cost pressures could present a “systemic barrier” for trusts responding to patient safety alerts, the Healthcare Safety Investigation Branch has warned.
In a report published today, the patient safety watchdog also demanded changes to the way national patient safety alerts were issued to hospitals. It found many NHS trusts had misinterpreted an alert meaning dozens of mistakes continued to happen.
It warned the financial costs of replacing equipment was a barrier to trusts responding to alerts and HSIB said this could be the case “particularly in private finance initiative hospitals” where trusts may have to renegotiate contracts to carry out capital works.
The latest investigation by the safety watchdog follows an incident where an 85-year-old woman was wrongly given normal air instead of oxygen after a nurse nearing the end of her shift connected the patient to the wrong wall mounted pipes.
The incident was the latest in a series of never events involving piped air being mistaken for oxygen. Patient safety alerts setting out actions for trusts to take were issued in 2009 and again in 2016. HSIB found many trusts had misinterpreted the alerts and considered the actions optional.
Despite this, between February and June 2018, 32 cases of patients being wrongly given air instead of oxygen were reported by NHS hospitals.
HSIB recommended the new national patient safety alert committee, chaired by national patient safety director Aidan Fowler, should set standards for safety alerts that require an assessment for unintended consequences, the effectiveness of barriers in the alert and the advice issued to providers on implementing changes.
It also suggested the central alerting system used to distribute alerts and record responses could be improved to allow providers to give more detail of actions they had taken, meaning a better national overview would be obtained.
Although HSIB identified issues around finances and PFI contracts, it did not make a formal recommendation. In a statement, it said it was not sure whether this was a general issue or specific to the trust investigated and more work would be needed to establish that.
However, it added: “The experience in other sectors is that what seem like straightforward recommendations from national bodies are difficult for providers to implement because of issues like this. It’s all part of what we are learning.”
Air and oxygen can be delivered to patient bedsides via pipes built into hospital walls with devices called flowmeters used to show the levels being delivered. Oxygen flowmeters are coloured white and air flowmeters are black. Both are located close together on the wall.
While the flowmeters cannot be connected to the wrong pipeline, the tubing used to connect the flowmeter to devices delivering oxygen to patients can be connected to both outlets.
NHS trusts were instructed to block off air outlets and instead use alternative devices but, where this was not possible, they were to ensure air flowmeters were removed from walls when not being used. Trusts were also told to fit moveable flaps over the air flowmeters as an extra warning to staff.
HSIB’s investigation found there was no consistent response to the safety alerts and that many trusts interpreted the three instructions as optional choices for them to select. As a result, most trusts opted only to fit moveable flaps to air flowmeters.
At the trust involved in the incident investigated by HSIB, it initially installed only moveable flaps and recorded its response to the national alert as completed in the CAS system. After a further incident, it issued a reminder to staff, but this did not prevent two more incidents. After a fourth incident, the trust purchased nebuliser boxes and restricted the use of piped air to only essential areas.
Kevin Stewart, medical director at HSIB, said: “Our investigation highlighted that despite the work that has gone into this, we are still seeing the same issues. In this particular case, as well as finding that there is a lack of clarity over the need for piped medical air in hospitals, financing and resourcing might also be a systemic barrier for trusts.”
Dr Stewart continued: “Although the patient in this case wasn’t harmed, there could have been a very different outcome. Rather than equipment design, we felt that it would be more effective for our recommendation to feed into the work being done by the national patient safety alert committee.”
Responding to the HSIB report, a Department of Health and Social Care spokeswoman said: “We are clear that financial considerations should never come at the expense of patient safety.
“We will work with the NHS to respond to these recommendations.”
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