National Health Service (NHS) England has issued a patient safety alert over the risk of severe harm and death from unintentional interruption of noninvasive ventilation (NIV).
The alert has been issued to raise awareness of the problem, after national monitoring highlighted it as a risk, said NHS England in a statement.
It said the National Reporting and Learning System had identified patient safety incidents where harm has been caused when the oxygen supply was found to be disconnected.
In one incident a mask for NIV was attached to a patient’s face but the ventilation machine had not been switched on. The patient became severely hypoxic and died.