COVID Safety Bulletin

The rapid learning and the huge volume of changes in practice that are needed to cope with the critical care of COVID-19 patients is meaning that many staff are having to adapt to continuous change. Inevitably issues and problems will arise. Our aim is to circulate lessons learned as quickly as possible to help care for patients and staff.

ViRUS 9: 05 May 2020

High risk of aerosolization or droplet spread from tracheostomy in patients with COVID-19 when ventilator or CPAP circuit disconnected

ViRUS 8: 30 Apr 2020

Problems during the use of anaesthetic machine ventilators with Covid-19 patients when no more dedicated ICU ventilators are available. These include: HME filter blockage, high inspired CO2 with spent soda lime and loss of ventilatory flow during suction.

ViRUS 7: 29 Apr 2020

Dry sputum and secretions in a ventilated patient causing endotracheal tube occlusion when dry circuit in use

ViRUS 6: 28 Apr 2020

What happens if your oxygen pipeline pressure drops?

ViRUS 5: 27 Apr 2020

Sudden HME Filter occlusion during proning

ViRUS 4: 15 Apr 2020

Slowness to recognise or seek help for respiratory patients on mechanical ventilation, including desynchrony, tachypnoea on pressure support and episodes of desaturation. Failure to recognise importance or urgency of problems and seek help.

ViRUS 2: 03 Apr 2020

Risk of aerosol generation from disconnection during movement of head in intubated prone patient.

ViRUS 1: 01 Apr 2020

Poor ventilation occurred in patients who were mechanically ventilated using a dry circuit with HME filters in place between catheter mount and rest of circuit, due to clogging in the HME filter.


We have created a simple survey that anyone can complete to indicate a safety issue experience during the epidemic. The link can be found here.

We will produce regular, short bulletins for circulation to members from the data we receive via this link and add them to this webpage.

Want to know more?
Browse our Standards pages.