Practice Safety Alerts

Improving the safety of oxygen therapy in hospitals: summary of a safety report from the National Patient Safety Agency

BMJ 2010; 340 doi: (Published 26 January 2010) Cite this as: BMJ 2010;340:c187
  1. Tara Lamont, head of response1,
  2. Dagmar Luettel, clinical reviewer1,
  3. John Scarpello, deputy medical director1,
  4. B Ronan O’Driscoll, respiratory physician2,
  5. Steven Connew, biomedical engineer3
  1. 1National Reporting and Learning Service, National Patient Safety Agency, London W1T 5HD
  2. 2Salford Royal NHS Foundation Trust, Salford M6 8HD
  3. 3Colchester Hospital University NHS Foundation Trust, Colchester CO4 5JL
  1. Correspondence to: T Lamont, tara.lamont{at}

    Why read this summary?

    Oxygen is used commonly and can save lives by preventing severe hypoxaemia.1 However, serious harm is possible if oxygen is not managed properly and the risks are poorly understood by trainee doctors and others.2 Underuse of oxygen can cause hypoxic organ damage, whereas overuse may harm neonates or cause hypercapnic respiratory failure in patients with chronic obstructive pulmonary disease.

    From December 2004 to June 2009, healthcare staff reported 281 serious incidents relating to oxygen use to the National Patient Safety Agency in England and Wales. Among these incidents, poor oxygen management seems to have caused nine deaths and may have contributed to a further 35 deaths. A typical incident report reads: “Patient [has] known type 2 respiratory failure with a diagnosis of COPD [chronic obstructive pulmonary disease] and who had previously required BIPAP [bilevel positive airway pressure] to control hypercapnia, [and was] switched to 15 litres O2 via face mask by nurse as he had low saturations, without the advice of a doctor. The patient was seen several hours later, GCS3 [Glasgow coma score 3], profound respiratory acidosis. Cardiac arrest and died that afternoon.”

    This summary is based on a safety report (known as a “rapid response …

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