National Patient Safety Alert: Interruption of high flow nasal oxygen during transfer

The alert relates to the risk of harm caused by the interruption of high flow nasal oxygen (HFNO) to babies, children and adults in acute respiratory failure without hypercapnia during patient transfer.

SPS commentary:

Some HFNO delivery devices have a transport mode, but most require mains power and will not deliver oxygen during transfer unless attached to a compatible uninterruptible power supply (UPS) device.


Providers are asked to add clear labels to these devices to make staff aware that even brief interruptions to mains power supply could lead to respiratory and cardiac arrest; and that HFNO in any emergency department or short stay unit must not be started without a plan for how to transfer the patient onwards.


Where a UPS is used, action must be taken on the storage and maintenance of UPS devices to ensure they are ready for use and staff know where to locate them.


Medicines and Healthcare products Regulatory Agency