Recurring concern
Unreliable monitoring of oxygen saturation during clinical care
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Request correctionFirst reported 4 Feb 2015•Latest report 21 Feb 2020
What this concern includes
Includes failures to initiate, perform, maintain or reliably use oxygen-saturation monitoring during clinical care, including paediatric oxygen blood monitoring and omitted or absent monitoring during hospital care.
Not included
- Excludes failures of oxygen prescribing, supply, delivery or administration where oxygen-saturation monitoring is not the deficient control.
- Excludes generic physiological-observation or clinical-record deficiencies unless they directly concern oxygen-saturation monitoring.
- Excludes failures to act on an oxygen-saturation result after monitoring was reliably completed.
- Excludes oxygen-equipment alarms or technical failures unless they directly prevent reliable oxygen-saturation monitoring.
- Reports
- 5
- Individual concerns
- 7
- Date range
- 2015–2020
- Stated actions
- 6
Distinct published reports
A report can raise multiple concerns
First to latest report issue date
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.
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.
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Concerns raised1
Oxygen-saturation monitoring failing to detect deterioration when oxygen levels do not deplete
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach 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
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Action
Update paediatric guidelines to strengthen recognition, senior assessment, monitoring and management of children with myopathies and hypokalaemia, including STRS contact indications.
Stated by Medway NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
NICE considers existing general guidance on assessment, monitoring, and altering care as indicated appropriate.
Stated by Department of Health and Social Care
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Concerns raised1
Failure to routinely use oxygen blood monitoring in paediatric medicine
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 concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to set pulse oximeter alarm levels to reflect individual patients’ baseline oxygen saturations
Responses linked to these concernsEach 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
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Action
Check pulse oximeter alarm settings across approximately 1,200 devices.
Stated by Betsi Cadwaladr University LHB -
Action
Scope an action plan addressing pulse oximeter alarm-level safety.
Stated by Betsi Cadwaladr University LHB -
Action
Raise pulse oximeter alarm-setting issues at Welsh and UK level through the MHRA.
Stated by Betsi Cadwaladr University LHB
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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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 LHB
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Concerns raised1
Failure to adequately record and monitor blood oxygen levels
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach 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.2
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Action
Maintain and use a hospital-wide documentation standards audit, recording variances and sharing results through peer review.
Stated by BMI The Alexandra Hospital -
Action
Notify relevant nursing staff that notes must record observations taken after patients are removed from oxygen.
Stated by BMI The Alexandra Hospital
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
Oxygen saturation readings of 90–92% were generally considered adequate for a patient who smoked, although the 89% reading was not adequately documented.
Stated by BMI The Alexandra Hospital
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Concerns raised3
Failure to monitor oxygen saturations before discharge after oxygen therapy
Failure to record oxygen saturations during hospital care
Failure to monitor oxygen saturations during hospital care
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 concernsEach 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
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Position
Oxygen saturations were monitored and recorded during the hospital attendance, contrary to the concern that they were not.
Stated by Tameside and Glossop Integrated Care NHS Foundation Trust
Data last updated 7 September 2026