A national patient safety alert has been issued by NHS England’s National Patient Safety team, in collaboration with the Faculty of Intensive Care Medicine (FICM), about the risk of harm from incorrectly assembled adult breathing circuits that lack a patent exhalation route for patients receiving invasive or non‑invasive ventilatory support.
Summary of required actions
– Organisations caring for patients on invasive and non‑invasive breathing circuits must:
– develop local guidance and visual aids for correct assembly and connection of breathing circuits;
– implement training covering specific safety checks to confirm a patent exhalation route; and
– establish clear processes for communicating updates to guidance.
– FICM has published a resource to assist with designing local guidance and visual aids: https://www.ficm.ac.uk/sites/ficm/files/documents/2025-02/FICM%20Breathing%20Circuits%20Resource.pdf
– All actions must be completed within 6 months.
– Original alert: https://www.england.nhs.uk/publication/national-patient-safety-alert-risk-associated-adult-breathing-circuits-lacking-patent-exhalation-route/
About national patient safety alerts
– This alert is a national patient safety alert issued by NHS England’s National Patient Safety team, the first national body accredited to issue such alerts by the National Patient Safety Alerting Committee (NaPSAC). NaPSAC responsibilities now sit with the National Patient Safety Committee (https://www.england.nhs.uk/patient-safety/patient-safety-systems/committee/).
– Alerts must meet NaPSAC thresholds and standards, developed with input from patients, frontline staff and experts, and provide clear, effective actions for safety‑critical issues (https://www.england.nhs.uk/patient-safety/national-patient-safety-alerting-committee/).
– The National Patient Safety Committee requires providers to introduce systems for planning and coordinating actions across organisations, with executive oversight.
– Failure to implement required actions may lead to Care Quality Commission regulatory action. National patient safety alerts are distributed via the Central Alerting System: https://www.cas.mhra.gov.uk/Home.aspx
