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

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 …