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Our colleagues at NHSI have been made aware of a small number of incidents reported to the National Reporting and Learning System (NRLS) suggesting inability to detach or disengage the probe and hosing of respiratory support devices, in particular ventilators, from the Schrader outlet of integral valve oxygen cylinders.

From a patient safety perspective this presents a significant issue for ventilated patients using integral valve oxygen cylinders during inter and intra hospital transfers if the cylinder becomes empty and needs changing, and the ventilator tubing can’t be released from the empty cylinder.

Oxygen cylinder manufacturers and the MHRA are investigating the underlying cause of the issue, however this may take some time. Whilst the MHRA are investigating the precise mechanism of the issue, please be vigilant and  “Report suspected or actual adverse events involving these devices through your local incident reporting system and/or your national incident reporting authority as appropriateEnglandScotlandNorthern IrelandWales. You should also report directly to manufacturers if your local or national systems do not.” 

Note: being mindful to include ventilator make and model, cylinder make, size and release mechanism, as well as hose supplier in your report. This will allow the MHRA to gain useful insight and expedite understanding of the issue and potential resolutions. You should also ensure that you have access to appropriate backup devices at all times.

The MDSO forum has some useful information and background to share with members too.

 

 

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