First reported 24 Nov 2014•Latest report 15 Jan 2026
Definition
What this concern includes
Includes failures in alarms dedicated to monitoring oxygen therapy, including missing or incorrectly configured upper or lower limits, failure to distinguish minor from critical oxygen-delivery problems, inadequate alarm prioritisation, and unreliable reactivation or escalation when an oxygen-related alarm occurs.
Not included
Excludes general patient-monitoring alarm failures where oxygen therapy is not the material safety concern.
Excludes failures to measure or monitor oxygen saturation where no oxygen-therapy alarm deficiency is identified.
Excludes oxygen prescribing, administration, supply or equipment failures that do not concern the alarm control itself.
Excludes failures to respond after an oxygen-therapy alarm has operated reliably and clearly.
Reports
4
Distinct published reports
Individual concerns
7
A report can raise multiple concerns
Date range
2014–2026
First to latest report issue date
Stated actions
8
Described in published responses
Reports over time
Reports over time
Reports about this concern issued each year.
* 2026 is projected from reports observed to 7 Sep 2026.
Most frequent recipients
Most frequent recipients
Reports about this concern sent to each recipient.
Betsi Cadwaladr University LHB1
Dolby Vivisol1
Invacare Limited1
Medicines and Healthcare products Regulatory Agency1
NHS England1
Salter Labs1
the Shrewsbury and Telford Hospital NHS Trust1
Company1
Executive non-departmental public body1
Local health board1
Medicines and medical devices regulator1
NHS trust1
Concerns and responses across reports
Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.
Shropshire, Telford and Wrekin
Concerns raised3
Failure to establish routine practice of setting upper alarms on bedside oxygen meters
Uncertainty over whether bedside oxygen meters can be set with an upper alarm
Failure to set an upper alarm on bedside oxygen meters
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Upper oxygen alarms are not used because lower alarms with regular monitoring better address the greater risk of low oxygen levels.
Stated by the Shrewsbury and Telford Hospital NHS TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Inner North London
Concerns raised2
Difficulty determining the cause of low oxygen saturations amid simultaneous CPAP alarms in medical wards
Failure of CPAP alarms to distinguish minor mask leaks from total cessation of oxygen supply
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
Action
Review the designated medical-equipment alarm standard and its application to alarm severity and prioritisation.
Stated by Medicines and Healthcare products Regulatory AgencyStated completedThe respondent said that this action was complete when they made their response on 3 August 2021.
Action
Engage respiratory and anaesthesia professional bodies to explore training and healthcare-system measures addressing audible alarm prioritisation.
Stated by Medicines and Healthcare products Regulatory AgencyStated in progressThe respondent said that this action was in progress when they made their response on 3 August 2021.
Action
Engage with the Faculty for Intensive Care Medicine to include disconnection-alarm guidance addressing alarm indications and response urgency.
Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 3 August 2021.
Action
Search the MHRA adverse-incident and corrective-action database for comparable ventilator alarm events.
Stated by Medicines and Healthcare products Regulatory AgencyStated completedThe respondent said that this action was complete when they made their response on 3 August 2021.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
The available evidence does not indicate a wider safety concern involving inability to identify ventilator faults from audible alarm tones.
Stated by Medicines and Healthcare products Regulatory AgencyDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Existing internationally recognised alarm standards, user training and manufacturer guidance sufficiently mitigate residual risks, so wholesale audible alarm redesign is not justified.
Stated by Medicines and Healthcare products Regulatory AgencyExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Changes to CPAP alarm design fall within the Medicines and Healthcare products Regulatory Agency’s remit.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
North Wales (East and Central)
Concerns raised1
Failure to set pulse oximeter alarm levels to reflect individual patients’ baseline oxygen saturations
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
Action
Check pulse oximeter alarm settings across approximately 1,200 devices.
Stated by Betsi Cadwaladr University LHBStated completedThe respondent said that this action was complete when they made their response on 21 December 2015.
Action
Scope an action plan addressing pulse oximeter alarm-level safety.
Stated by Betsi Cadwaladr University LHBStated completedThe respondent said that this action was complete when they made their response on 21 December 2015.
Action
Raise pulse oximeter alarm-setting issues at Welsh and UK level through the MHRA.
Stated by Betsi Cadwaladr University LHBStated plannedThe respondent said that this action was planned when they made their response on 21 December 2015.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Some pulse oximetry alarm-setting issues concern manufacturers and should be addressed through Wales- and UK-level channels, including the MHRA.
Stated by Betsi Cadwaladr University LHBRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Surrey
Concerns raised1
Absence of a visual or audible alarm indicating loss of oxygen flow to the nasal cannula
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Action
Assess whether an alarm can detect oxygen-flow loss caused by an improperly engaged humidifier cap.
Stated by Invacare (UK) LimitedStated completedThe respondent said that this action was complete when they made their response on 24 November 2014.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.6
Position
The humidifier’s existing safety valve and leak-test instructions provide warnings for blockages and leaks, including cross-threading-related leaks.
Stated by Salter LabsExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
The concentrator manufacturer is responsible for addressing the absence of a visual or audible alarm for lost oxygen flow.
Stated by Salter LabsRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Equipment manufacture and design concerns fall outside the company’s functions, so it cannot respond to them.
Stated by Dolby VivisolOutside remitThe respondent said that this matter was outside its role or authority.
Position
Equipment manufacture and design concerns should be addressed by the relevant manufacturers, Invacare and Salter Labs.
Stated by Dolby VivisolRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Existing alarms detect relevant concentrator faults, comply with applicable standards, and are considered sufficient without additional alarms.
Stated by Invacare (UK) LimitedExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
An alarm detecting oxygen loss at the humidifier would be technically complex and introduce unacceptable risks and inconvenience without sufficient benefit.
Stated by Invacare (UK) LimitedUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
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Includes failures in alarms dedicated to monitoring oxygen therapy, including missing or incorrectly configured upper or lower limits, failure to distinguish minor from critical oxygen-delivery problems, inadequate alarm prioritisation, and unreliable reactivation or escalation when an oxygen-related alarm occurs.
