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Risk of harm from acupuncture treatment including pneumothorax | Signal

Reference number
1324
Issue date29 September 2011
TypeSignal

This Signal concerns the risk of harm caused by acupuncture treatment.

 

A sample report extract reads:

 

……patient attended physiotherapy for her second Ogilvie Syndrome acupuncture session. Then today [date] the patient called to advise me that after the acupuncture she has received, she had collapsed and had breathing difficulties a short while later. The GP was called to her house and she was no better so went to A&E who did a chest X-ray to find that she had a pneumothorax…....The doctor told the patient that this may have been caused by the acupuncture through a needle piercing the lung....”  

 

A search of the National Reporting and Learning System found 34 patient safety incidents related to acupuncture treatment reported as severe or moderate harm between November 2003 and March 2011. In addition, 95 relevant incidents were reported between January 2010 and March 2011 as low or no harm.

 

Five of these incidents described a pneumothorax as a result of acupuncture treatment. Pneumothorax is a known risk for acupuncture treatment and research has suggested that good technique reduces the risk. Other patient outcomes included temporary loss of consciousness, fainting, feeling dizzy or unwell.

 

Other issues identified are:

·         Acupuncture needles being left in the patient following treatment;

·         a lack of clarity regarding correct emergency procedures; and

·         a lack of functioning equipment such as call bells and resuscitation bags. This was particularly apparent in isolated locations such as small self-contained physiotherapy units some distance from the main hospital.

 

NHS organisations carrying out acupuncture should ensure that:

·         A procedure is in place to ensure that acupuncture needles are not inadvertently left in the patient;

·         acupuncture is carried out in locations where emergency help can be readily summoned; and

·         local policies include details of qualifications and experience required by practitioners including appropriate skills for dealing with emergency situations.

 

We would like to hear from you - please contact us with your initiatives to reduce risks in these areas.

 

Signals are notifications of key risks emerging from review of serious incidents reported to the NRLS and shared by the NPSA.