A national patient safety alert has been issued by the NHS England National Patient Safety team – in collaboration with the Faculty of Intensive Care Medicine – about the risk of harm from incorrectly assembled breathing circuits lacking a proper exhalation route for patients receiving invasive or non-invasive ventilatory support.
About this alert
There are reports of patients who have come to harm or been exposed to potential harm because the breathing circuit to which they were connected was incorrectly assembled.
The alert requires organisations caring for patients on invasive and non-invasive breathing circuits to develop local guidance and visual aids for the assembly and connection of breathing circuits, implement training on specific safety checks, and establish clear processes for communicating updates to guidance.
The Faculty of Intensive Care Medicine has published a resource to help with the designing of local guidance and visual aids to support the safe setup of invasive and non-invasive breathing circuits.
All actions must be completed within 6 months.
About national patient safety alerts
This alert has been issued as a national patient safety alert.
The NHS England National Patient Safety team was the first national body to be accredited to issue national patient safety alerts by the National Patient Safety Alerting Committee (NaPSAC), whose responsibilities now come under the National Patient Safety Committee.
All national patient safety alerts are required to meet NaPSAC’s thresholds and standards. These thresholds and standards include working with patients, frontline staff and experts to ensure alerts provide clear, effective actions for safety-critical issues.
The National Patient Safety Committee requires providers to introduce new systems for planning and co-ordinating the actions required by any national patient safety alert across their organisation, with executive oversight.
Failure to take the actions required under any national patient safety alert may lead to the Care Quality Commission taking regulatory action. National patient safety alerts are shared rapidly with healthcare providers via the Central Alerting System (CAS).
