Patient Safety Alert - Pulse Oximeter

Patient Safety

We’re reminding staff of NHS Improvement’s patient safety alert regarding the correct placement of pulse oximeter probes.

This follows a recent incident where ‘silent hypoxia’ was missed on a patient with COVID-19.

Patients most at risk of poor COVID-19 outcomes are best identified by oxygen levels.
The use of oximetry is an important tool in monitoring and identifying ‘silent hypoxia’ and rapid patient deterioration at home..

However, if an oximeter probe intended for the finger is attached to the ear (or vice versa), or a probe intended for an adult is attached to a baby or a child (or vice versa), it can produce a reading up to 50% lower or 30% higher than the real value.

The clinical implication of an inaccurately high reading, is that staff may be falsely reassured about a patient’s condition, when in reality the patient is deteriorating, or may make an inappropriate intervention when in fact a patient is stable or improving.

Ensuring the correct probes are used and placed appropriately is therefore essential.

NHS Improvement has issued the following patient safety alert to all NHS Trusts regarding the risk of harm from inappropriate placement of pulse oximeter probes.
Please read the full bulletin here 


Published 25th March 2021