Safety spotlight: Nitrous oxide

An investigation found that some members of the anaesthetic team were not included in theatre communications and information being shared across the Trust. As a result, the anaesthetic team did not know that the nitrous oxide gas supply (known as decommissioning) was switched off in the maternity theatre before a general anaesthetic was given.

The team only realised the gas supply was unavailable after the operation had started, when it became clear that nitrous oxide was not being delivered through the anaesthetic machine. They had to act quickly and switch to an alternative supply using a gas cylinder attached to the anaesthetic machine.

The mother was not harmed on this occasion.

To minimise this happening in your service, consider the following:

• How does the Trust ensure that staff across all departments receive safety communications relevant to their speciality, including staff affected by equipment changes in the maternity theatre complex?
• What process does the Trust use to ensure that all theatre equipment is checked and working before each procedure?
• Are senior anaesthetic doctors represented on the Trust’s medical gases committee to ensure key stakeholders are involved in decision-making in line with a nationally recognised toolkit?

Please note that for the purposes of this safety spotlight, ‘decommissioning’ refers to capping off the terminal units in operating theatres and removing the large nitrous oxide cylinders (the manifold) that supply the pipeline. It does not refer to Entonox pipelines to birth rooms.