Using Medical Gases Appropriately

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Must read background material and guidance to support good medical gas use for hospital Chief Pharmacists and their teams

Responsibilities of Chief Pharmacists and their teams for medical gases

Many medical gases and specifically medical oxygen are regulated as Medicinal Products. Chief Pharmacists are therefore responsible for governance and ensuring availability and safe use in exactly the same way as for other medicines.

More detail on the role of the Chief Pharmacist

Further guidance on the role of the Chief Pharmacist in relation to medical gases is provided in the attachment below.

National reports and incident reporting


In September 2009, the National Patient Safety Agency (NPSA) Rapid Response Report RRR006 noted 281 reports of serious incidents (up to June 2009) related to inappropriate administration and management of Oxygen. Of these incidents, poor oxygen management may have caused nine patient deaths and may have contributed to a further thirty five.

In June 2010, the risk associated with unsecured cylinders was highlighted following the death of a patient (EFA/2010/008)

In October 2016, NHS Improvement released the Patient Safety Alert, ‘Patient Safety Alert: Reducing the risk of oxygen tubing being connected to air flowmeters‘ following incidents in which tubing had been connected to the wrong flow meter.

In April 2018, NHS Improvement issued Patient Safety Alert NHS/PSA/W/2018/001: Risk of death and severe harm from failure to obtain and continue flow from oxygen cylinders.

In January 2023 NHS England issued Patient Safety Alert NatPSA/2023/001: Use Of Oxygen Cylinders Where Patients Do Not Have Access To Medical Gas Pipeline Systems

Common themes

Common themes identified from the review of the incidents above, local investigations and other sources were:

  • Prescribing: inappropriate use, without prescription
  • Administration: confusion of oxygen with medical compressed air, incorrect flow rates, inadvertent disconnection of supply; inadequate attention to flow rate
  • Monitoring: patients not monitored, abnormal oxygen saturation levels not acted upon
  • Equipment: poor maintenance, empty or unstable cylinders, faulty and missing equipment
  • Fires: affecting patients through mismanagement of oxygen

COVID-19 and Oxygen Supply

In Spring 2020, the COVID-emergency placed wholly unprecedented demands on hospital medical oxygen pipeline systems and medical oxygen cylinder supplies, and resulted in situations in which oxygen supplies were critically depleted to levels which presented a threat to patient care. An even more serious situation emerged in Autumn 2020.

In response in April 2020 MHRA issued CAS Alert NHSE/I-2020/001: Use of high flow oxygen therapy devices during the coronavirus epidemic.

Update history

  1. added link to new NatPSA Alert
  1. Medical gasses are under constant review and article series remains valid. Full content review due 2022, or sooner if National guidance dictates.
  1. Published

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