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IRIC safety alert

Estates and Facilities Notice – EFN2302

Published on 23 November 2023

From: NHSScotland Assure

EFN2302 - Oxygen Regulator fitted to Medical Air Cylinder

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Details

A bullnose regulator marked for oxygen administration was attached to a medical air cylinder in error and placed on a transfer trolley. The cylinder colour coding and label indicated medical air. A portable ventilator was connected to the oxygen regulator on the medical air cylinder in preparation for a patient requiring oxygen while being transferred. The ventilator’s ‘low oxygen’ alarm sounded to alert staff and the medical air cylinder was replaced with an oxygen cylinder. (Note: some ventilators may not have a ‘low oxygen’ alarm.) Within the UK and Ireland, the same type of bullnose connector is used on cylinders of several different medical gas products and lets a regulator marked for administration of a particular medical gas be connected to a cylinder containing a different gas.