Hospital bosses in Calderdale have taken measures to prevent potentially-fatal safety incidents in which patients were wrongly given medical air instead of oxygen.
The mistake has been reported 57 times at hospitals in England since it was classed as a “never event’ by health service bosses in February 2008, according to NHS incident reports.
That included three times at Leeds Teaching Hospitals NHS Trust, three times at Calderdale and Huddersfield NHS Foundation Trust and once at York Teaching Hospital.
Bosses have since removed or capped airflow points to protect against it happening again.
Jackie Murphy, director of nursing at Calderdale and Huddersfield, said: “We have taken immediate action to ensure these incidents are not repeated. Our air outlets are now either permanently capped or semi-permanently capped with extra signage in place.
“No patients were harmed and our Trust continues to be committed to providing safe and compassionate care.”
Trusts around the country were told to remove airflow metres which were wrongly used to administer gas to patients,
But some misinterpreted the guidance, said a report by the Healthcare Safety Investigation Branch (HSIB).
The HSIB investigation found some trusts failed to implement the recommendations, sometimes due to the cost of changing equipment.
Acting Leeds Teaching Hospitals chief executive Yvette Oade said: “Thankfully none of the incidents caused harm to the patients involved and no further incidents have occurred since May 2018.
“We removed the air supply from areas where it isn’t needed and added an additional safety feature to bedside medical gas supply systems to prevent inadvertent administration of medical air."
Oxygen is used to treat patients during medical emergencies to boost low blood oxygen levels and reduce breathlessness.
Medical air is used in nebulisers, which convert medication into gas, and in ventilators for patients who are sensitive to oxygen.