HSIB Report on their ‘Investigation into the piped supply of medical air and oxygen'

The Healthcare Safety Investigation Branch (HSIB) have issued (28 February 2019) their report into their investigation into the piped supply of medical air and oxygen.
https://www.hsib.org.uk/investigations-cases/piped-supply-medical-air-and-oxygen/

https://www.hsib.org.uk/investigations-cases/piped-supply-medical-air-and-oxygen/final-report/

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.

The NHS Patient Safety Alert issued in October 2016.

The HSIB summary report.

The HSIB final report.

For more information on the HSIB - www.hsib.org.uk

5 March 2019

 

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