Oxygen valve.

Piped supply of medical air and oxygen

HSIB legacy content

HSIB legacy content

This investigation was carried out by the Healthcare Safety Investigation Branch (HSIB). Find out more about HSIB legacy.

Investigation summary

This investigation focuses on the design and implementation of patient safety alerts. It follows a reference event where an 85-year old woman was connected to the piped medical air supply, instead of the oxygen supply, whilst she was receiving hospital treatment after a fall at home.

We were made aware of a safety issue relating to a persistent risk in hospitals of connecting oxygen tubing to wall-mounted air flowmeters, despite the release of a Patient Safety Alert by NHS Improvement in 2016 and a Rapid Response Report from the National Patient Safety Agency in 2009 intended to address this issue.

Since being classified as a never event – a serious incident that is entirely preventable – in February 2018, 32 cases of unintentional connection to air instead of oxygen have been reported (1 February 2018 to 30 June 2018). 

The investigation found that NHS trusts may have misinterpreted the direction of the alert and that the central alerting system doesn’t capture the detail of actions taken by providers in response to alerts.

Investigation report