AUTHOR BIOGRAPHIES
Lucy S. Bocknek, MS, OTR/L, MedStar Health National Center for Human Factors in Healthcare
Lucy S. Bocknek is a human factors and safety scientist at the MedStar Health National Center for Human Factors in Healthcare.
Deanna-Nicole C. Busog, BS, MedStar Health National Center for Human Factors in Healthcare
Deanna-Nicole C. Busog is a research analyst at the MedStar Health National Center for Human Factors in Healthcare.
Raj M. Ratwani, PhD, MedStar Health National Center for Human Factors in Healthcare, Georgetown University School of Medicine
Raj M. Ratwani is the director of the MedStar Health National Center for Human Factors in Healthcare, vice president of scientific affairs at the MedStar Health Research Institute, and an associate professor at Georgetown University School of Medicine.
Katharine T. Adams, MS, MedStar Center for Biostatistics, Informatics, and Data Science
Katharine T. Adams is a data scientist at the MedStar Center for Biostatistics, Informatics, and Data Science.
Rebecca Jones, MBA, RN, Patient Safety Authority
Rebecca Jones (rebejones@pa.gov) is director of Data Science & Research at the Patient Safety Authority.
*Corresponding author
Seth Krevat, MD, MedStar Health National Center for Human Factors in Healthcare, Georgetown University School of Medicine
Seth Krevat is the senior medical director at the MedStar Health National Center for Human Factors in Healthcare and an assistant professor at Georgetown University School of Medicine.
Abstract
Background
Medical oxygen is frequently used in healthcare settings. Challenges with oxygen disruption, such as oxygen tanks running out due to communication issues between staff or tanks not being set up properly, have been noted in the limited existing literature. Challenges and patient safety issues associated with oxygen disruption persist. Utilizing a human factors approach, our study aims to understand the contributing factors and context of oxygen disruption–related patient safety event reports in the inpatient setting and provide person-based and system-based solutions.
Methods
Through keyword matching, we identified and then qualitatively analyzed 298 patient safety event reports to understand the factors contributing to oxygen disruption, patient location when the oxygen disruptions occurred, hand-off breakdowns by healthcare team member role, and whether high supplemental oxygen was being administered.
Results
The most frequent contributing factor to oxygen disruption was the patient not being transferred to another source of oxygen (n=135 of 298, 45.3%), followed by tank found empty (n=107, 35.9%), patient connected to a functioning oxygen source, no oxygen flowing (n=25, 8.4%), oxygen delivery device malfunction (n=22, 7.4%), and no oxygen available (n=9, 3.0%). Over one-third of all oxygen disruption events occurred on the unit where the patient was admitted (n=109 of 298, 36.6%). Roughly 40% of reports involved a hand-off breakdown (n=123 of 298, 41.3%) and the most frequent breakdowns occurred between a nurse and a patient transporter (n=47 of 123, 38.2%). Almost one quarter of reports involved a patient with high supplemental oxygen requirements (n=74 of 298, 24.8%).
Conclusion
Oxygen disruption events can have serious patient safety implications. Many of the oxygen disruption events we reviewed occurred due to lack of situational awareness and hand-off breakdowns. Combining person-based solutions, such as paper-based tools and checklists, with system-based solutions involving central monitoring and supervisory systems may help reduce the risk of oxygen disruption events.
