Problem: During the Covid-19 pandemic it became apparent that historic measures were inadequate to prevent harm to patients requiring oxygen therapy. In the Emergency Department of a large acute care hospital in Michigan, rapid cycle improvement strategies helped to maintain safety during heavy patient surges.
Measurement: In 2020-2021, 11 adverse events related to oxygen (o2) safety were reported, as compared zero in the 18 months prior to the first COVID-19 admission. These events were dubbed “No O2” events. Each of these events were reviewed by the patient safety and emergency department leadership.
Analysis: RCAA and a FMEA were completed to identify root causes and failure modes. Results showed trends towards: failure to connect to wall source, flow rate exceeding tank supply, and patient placement challenges. Gemba walks, equipment and supply changes, staff interviews, and mapping the current state were also completed.
Implementation: New strategies included communication via job aides, signs and huddle messages, frequent rounding on hallway patients requiring o2, increased daily tank delivery and the purchase, installation and use of portable pulse oximeters and hallway call lights. Use of H-cylinder o2, handoffs and tanks with alarms were also considered.
Results/Discussion: As this latest COVID-19 surge wanes, and due to our implementation strategies, we have seen a rapid decline in No O2 events. We have had 2 No O2 events in 2022 related to handoffs, which is an action item that remains in progress. O2 safety will remain a 2022 priority.
