It is recognised that the risk of smoking while using health services both as an in-patient or outpatient increases the risk of potential harm. The purpose of this Patient Safety Supplement is to raise awareness of the significant risks of smoking and vaping in a healthcare setting and support staff to explain these risks to patients to enable their safety and that of other patients and staff. It also empowers staff including smoking cessation officers working in a health promoting environment to provide support for patients through available resources and therapies. Incident analysis sought to identify any common risks or incidents associated with smoking and this supplement shares the learning from incidents reported to the National Incident Management System (NIMS) relating to smoking in Acute Hospital Services.
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Patient Safety Incident Reporting in Ireland
A review of smoking related incidents reported to NIMS from 2018 to 2022 showed there were approximately 3,700 incidents reported onto NIMS relating to smoking in acute hospital services in Ireland. Over 180 of these incidents resulted in harm to either patients, visitors or staff of which over 100 of these incidents required medical treatment. Four serious incidents associated with smoking in the five-year period lead to severe harm or death of patients.
Smoking Related Scenarios in Irish Healthcare Services
Smoking near Oxygen: Over 2,000 incidents of indoor smoking have been recorded on NIMS since 2018. While each incident poses a potential fire risk, it is especially concerning that over 100 incidents have been reported where patients or visitors have lit cigarettes while using or being close to Oxygen. Oxygen is a highly combustible gas and as a result a number of fires have occurred, resulting in burns (some significant) and smoke inhalation injuries to the patient, other patients and staff. Unfortunately, in more serious incidents patient deaths have occurred.
Aggression towards staff: Verbal and physical abuse of staff and other patients by patients requesting to smoke is a recurring theme in reported cases. The risk and management of aggression and violence in health services is not caused by implementation of the tobacco policy or unique to tobacco management but needs to be documented and addressed as per HSE policy.
Smoking after using Alcohol Gel: Alcohol gel is regularly used as a hand sanitiser in hospitals. When a cigarette is lit after use of alcohol gels, the flame can react with the alcohol and cause it to ignite which has resulted in both minor and moderate burns to patients’ hands and face.
Other: Ongoing challenges are encountered when patients leave health services to have a cigarette. Predominantly these were incidents where patients did not return or fell resulting sometimes in serious injuries including fractures.
Expert Comment
by Martina Blake, National Lead - HSE Tobacco Free Ireland Programme
"It is HSE policy that all HSE and HSE funded hospitals are tobacco free campuses. Patients expect to receive healthcare in a clean, smoke free environment. However, tobacco addiction and withdrawal from nicotine is not commonly assessed or treated on admission and can be challenging for patients to manage. Best practice indicates that smoking status should be assessed and treatment with Nicotine Replacement Therapy (NRT) offered on admission to manage nicotine withdrawals. This should commence regardless of intention to quit. Patients and their families should be consulted and advised not to bring tobacco products and paraphernalia such as lighters into hospitals and other care settings. Staff should be aware of all the resources available to support patients not to smoke while in hospital. Smoking while an in-patient has associated risks and the Tobacco Free Ireland Programme is aware of a number of significant injuries and subsequent deaths that have occurred in Irish health services due to cigarette related fires and injuries. All staff but particularly those with responsibility for health and safety management should be cognisant of the risks associated with breaches to the policy and smoking/vaping both indoors and outdoors."
Patient Safety Strategies for a tobacco free campus
- Stop Smoking—National Clinical Guideline No. 28 – January 2022
- HSE Tobacco Free Campus Policy
- How to Implement HSE Tobacco Free Campus Toolkit
- Policy on the Prevention and Management of aggression and violence
International Evidence and Best Practice
HSE Recommendations
- Work with patients to support the treatment and management of their addiction and continue to assist patients not to use tobacco while using health services.
- Record smoking status of all patients routinely recorded on admission. To support patients, it is essential that they receive early intervention and are prescribed NRT to manage tobacco dependence and withdrawal, regardless of their intention to quit or the duration of stay.
- Communicate Tobacco Free Campus Policy expectations formally pre-admission or at outpatient appointments, including advising patients to leave tobacco products, e-cigarettes and lighters at home.
- Frontline healthcare staff should complete Making Every Contact Count training online on HSeLanD https://www.hseland.ie/dash/Dashboard and refer patients who smoke to a relevant specialist HSE stop smoking services.
- HSE staff are advised to complete the HSeLanD Supporting Staff to Communicate the HSE Tobacco Free Campus Policy eLearning module https://www.hseland.ie/dash/Dashboard
- Ensure local health and safety processes take account of the fire risk posed due to smoking and include relevant risk management advice, such as that in product information for medicinal air/oxygen on user education, storage and warning notices. Available via www.hpra.ie G. Report incidents of smoking indoors in a workplace to the National Tobacco Control Office - 1800 333 100 / info@tpd.ie
Comment from Patients for Patient Safety Ireland
"Patients for Patient Safety Ireland welcomes this supplement as an important step in raising awareness of the risks of smoking in a healthcare environment. The risks are clearly defined, backed up by data from real incidents in NIMS. This Patient Safety Supplement is an awareness document, explaining the reasons and importance of tobacco free environments and the real risk to patients who smoke. The recommendations will enable staff to provide support for patients who smoke and seek co-operation from us all to respect acute hospitals and their campuses as non-smoking areas, reducing those risks and improving safety for patients and staff. We acknowledge and support all reasonable measures to ensure healthcare facilities and environments are safe for patients, carers and staff. When individual personal choices create challenges to personal safety and the safety of others it is within the duty of service providers to do all they can to address those challenges and reduce risk."
Developed by
- HSE Tobacco Free Ireland Programme
- Patients for Patient Safety Ireland
- Patient Safety Together Team – QPS Incident Management, National Quality & Patient Safety Directorate, HSE
An additional Patient Safety Supplement regarding the impacts of smoking within our Community Health Services is under development.
For more information on Tobacco Free Ireland Programme please contact tfi@hse.ie
For more information on Patients for Patient Safety Ireland please contact info@patientsforpatientsafety.ie
For more information on Patient Safety Supplements please contact patientsafetytogether@hse.ie
The content of this Patient Safety Supplement (PSS) is current as of 22/02/2023. It includes the best available evidence at the time of writing. It is the responsibility of the reader to ensure that the information in this supplement remains in date. This PSS is the property of the HSE and subsequent re-use or distribution in whole or in part should include acknowledgment of the service.