PFI hospital ‘never events’ – Wrong pipe! 85-year-old given air instead of oxygen


HOSPITALS built under the hated Private Finance Initiative (PFI) do not respond well to ‘never events’ where patients’ lives are put in to serious jeopardy, the Healthcare Safety Investigation Branch (HSIB) warned yesterday.

One such ‘never event’ was an incident where an 85-year-old woman was wrongly given normal air instead of oxygen after a nurse nearing the end of her shift connected the patient to the wrong wall mounted pipes.

A report published yesterday, found many PFI hospitals did not react to ‘never events’ meaning that the same dangerous mistakes happened again and again.

It warned the financial costs of replacing equipment was a barrier to trusts responding to alerts.

It went further by singling out PFI hospitals as being particularly prone to this.

The watchdog said this is the case ‘particularly in Private Finance Initiative hospitals’ where trusts have to renegotiate contracts to carry out work.

The incident where the wrong air pipe was plugged in was cited by the watchdog as the latest in a series of ‘never events’ involving piped air being mistaken for oxygen.

Patient safety alerts setting out actions for trusts to take were issued in 2009 and again in 2016.

Despite this, between February and June 2018, 32 cases of patients being wrongly given air instead of oxygen were reported by NHS hospitals.

In other words the potentially deadly mistake happened again and again with no measures taken to change the equipment to make it impossible to reconnect the wrong pipe.

Air and oxygen can be delivered to patients’ bedsides via pipes built into hospital walls with devices called flowmeters used to show the levels being delivered.

Oxygen flowmeters are coloured white and air flowmeters are black. Both are located close together on the wall.

While the flowmeters cannot be connected to the wrong pipeline, the tubing used to connect the flowmeter to devices delivering oxygen to patients can be connected to both outlets.

NHS trusts were instructed to block off air outlets and instead use alternative devices but, where this was not possible, they were to ensure air flowmeters were removed from walls when not being used. Trusts were also told to fit moveable flaps over the air flowmeters as an extra warning to staff.

Dr Kevin Stewart, medical director at HSIB, said: ‘Our investigation highlighted that despite the work that has gone into this, we are still seeing the same issues.

‘In this particular case, as well as finding that there is a lack of clarity over the need for piped medical air in hospitals, financing and resourcing might also be a systemic barrier for trusts.’