NHS England’s National Patient Safety team, working with the Faculty of Intensive Care Medicine (FICM), has issued a national patient safety alert about the risk of harm from adult breathing circuits that are assembled or connected so that the patient has no patent (unobstructed) exhalation route. The alert covers patients on invasive and non‑invasive ventilatory support and highlights the potential for serious patient harm if exhalation is impeded.
Required actions (must be completed within 6 months)
– Develop local guidance and visual aids that clearly show correct assembly and connection of adult breathing circuits, ensuring an unobstructed exhalation route.
– Deliver training that includes specific safety checks to confirm the exhalation route is patent before use and during care transitions.
– Put in place clear processes to communicate updates to local guidance and to ensure consistent implementation across teams and departments.
– Use the FICM resource to help design local guidance and visual aids: https://www.ficm.ac.uk/sites/ficm/files/documents/2025-02/FICM%20Breathing%20Circuits%20Resource.pdf
– Complete all required actions within 6 months of the alert.
– Full original alert available here: 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 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 are issued only when thresholds and standards set with input from patients, frontline staff and experts are met; they provide clear, practicable 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 to ensure completion.
– Failure to implement required actions may prompt regulatory action by the Care Quality Commission. National patient safety alerts are distributed via the Central Alerting System: https://www.cas.mhra.gov.uk/Home.aspx
Action owners should ensure local policies, staff training, visual aids and communication pathways are updated promptly so that every adult breathing circuit in clinical use has a clearly verifiable, unobstructed exhalation route.
