Presentation
Design and Evaluation for Continuous System Improvement: Transporting Patients on Oxygen
SessionApplied Methods (HE9)
DescriptionIn this presentation, we will describe a human factors study that continuously evaluated the process of patient transport requiring oxygen, as part of the root cause analyses (RCAs) and proactive risk assessments (PRAs). The study involves a series of phases over more than six years, including the design, evaluation and implementation of a nomogram, the creation of oxygen tank design requirements, and the evaluation and implementation of new digital oxygen tanks.
Our embedded human factors implementation team is highly involved in the RCAs and PRAs within the health system. Human Factors Engineers participate in select RCAs and PRAs to support multidisciplinary efforts, and often conduct independent human factors studies (e.g., usability testing, Work System Analysis, ethnographies, etc.) on the process that is reflected in the events. Our findings contribute to the multidisciplinary analysis, design, discussion and decision-making. We collaborate with cross-functional teams across the organization to identify, develop and implement both short-term solutions and long-term solutions that may resolve the work system barriers and vulnerabilities.
Transporting Patients on Oxygen is a process with risks and potential errors. The oxygen tank may run out in the middle of a trip (especially during a long trip such as from the procedure area to an inpatient unit), creating opportunities for serious patient safety events. The time that the oxygen can last may need to be manually calculated at the beginning of a trip, based on the remaining volume and the flow rate. The calculation takes time and consumes mental resources in a work context where transportation may be emergent, and the transporter may be multi-tasking. The oxygen tank may run out very quickly with a high flow rate.
Throughout the years, we have implemented multiple solutions in phases to continuously address this issue. Human factors implementation team has been engaged in this process.
Phase 1: Design, Evaluate and Implement a Nomogram
We designed a Nomogram in a matrix with color coding on paper for the user to quickly determine the estimated empty time for transporting the patient. For example, if a patient is on 4L of O2 nasal cannula, using the Nomogram, the nurse can calculate how long the oxygen tank will be empty, and decide if they can make the trip. The empty time will be recorded on a sticker and placed on the oxygen tubing just below the patient’s neck that is easily visible to the transporter. The nomogram has been tested with frontline users and we received positive feedback on the ease of use. Human Factors engineers worked with the transportation committee to update the policy to standardize the use of nomogram. After the implementation, we saw a significant decrease of patient safety events in units that consistently used the sticker/nomogram.
Phase 2: Creation of Oxygen Tank Design Requirements
Despite the ease of use, after implementation, we learned that users may not use the nomogram in some scenarios, because starting a transportation may be emergent and under time pressure. Users may not have time to use the nomogram to calculate the empty time. We participated in additional RCAs and PRAs to review the process and conducted usability evaluations of the current oxygen tanks. We uncovered several usability barriers of the oxygen tanks, and developed the design requirements. We reported our findings to the RCA and PRA teams and advocated for new tanks that may provide automatic calculation for the users and auditory warnings. The new oxygen tanks that may meet the design requirements were identified, piloted, and planned for implementation.
Phase 3: Evaluation and Implementation of the New Digital Tank
One of our community hospitals served as a pilot site for the new digital tanks. We visited the site and conducted a heuristic evaluation of the new oxygen tank. The new tanks have several design features that would prevent potential errors, such as a visual digital display to show the remaining volume in number, a volume bar with color coding, an automatic calculation of the time remaining based on the flow rate, and auditory warnings when the oxygen tank is low and is at risk of running out within 15 minutes.
During the evaluation, we also identified some potential system barriers. For example, the icon to indicate an almost empty tank may be confusing and be interpreted by different users with different meanings. The interface showing the time remaining lacks a unit which may cause user confusion. The findings informed the sociotechnical system solutions during the implementation process.
In conclusion, RCAs or PRAs are opportunities for human factors engineering to contribute with a work system evaluation, which may result in positive system changes. The Human Factors studies may not end at the time of finishing the RCA or PRA. It may last for a few years to continuously identify the system barriers throughout the implementation process (for both short-term and long-term solutions). With a systems perspective in mind, we may design a robust and resilient system that truly addresses the system barriers/vulnerabilities to make it harder for an error to occur.
Our embedded human factors implementation team is highly involved in the RCAs and PRAs within the health system. Human Factors Engineers participate in select RCAs and PRAs to support multidisciplinary efforts, and often conduct independent human factors studies (e.g., usability testing, Work System Analysis, ethnographies, etc.) on the process that is reflected in the events. Our findings contribute to the multidisciplinary analysis, design, discussion and decision-making. We collaborate with cross-functional teams across the organization to identify, develop and implement both short-term solutions and long-term solutions that may resolve the work system barriers and vulnerabilities.
Transporting Patients on Oxygen is a process with risks and potential errors. The oxygen tank may run out in the middle of a trip (especially during a long trip such as from the procedure area to an inpatient unit), creating opportunities for serious patient safety events. The time that the oxygen can last may need to be manually calculated at the beginning of a trip, based on the remaining volume and the flow rate. The calculation takes time and consumes mental resources in a work context where transportation may be emergent, and the transporter may be multi-tasking. The oxygen tank may run out very quickly with a high flow rate.
Throughout the years, we have implemented multiple solutions in phases to continuously address this issue. Human factors implementation team has been engaged in this process.
Phase 1: Design, Evaluate and Implement a Nomogram
We designed a Nomogram in a matrix with color coding on paper for the user to quickly determine the estimated empty time for transporting the patient. For example, if a patient is on 4L of O2 nasal cannula, using the Nomogram, the nurse can calculate how long the oxygen tank will be empty, and decide if they can make the trip. The empty time will be recorded on a sticker and placed on the oxygen tubing just below the patient’s neck that is easily visible to the transporter. The nomogram has been tested with frontline users and we received positive feedback on the ease of use. Human Factors engineers worked with the transportation committee to update the policy to standardize the use of nomogram. After the implementation, we saw a significant decrease of patient safety events in units that consistently used the sticker/nomogram.
Phase 2: Creation of Oxygen Tank Design Requirements
Despite the ease of use, after implementation, we learned that users may not use the nomogram in some scenarios, because starting a transportation may be emergent and under time pressure. Users may not have time to use the nomogram to calculate the empty time. We participated in additional RCAs and PRAs to review the process and conducted usability evaluations of the current oxygen tanks. We uncovered several usability barriers of the oxygen tanks, and developed the design requirements. We reported our findings to the RCA and PRA teams and advocated for new tanks that may provide automatic calculation for the users and auditory warnings. The new oxygen tanks that may meet the design requirements were identified, piloted, and planned for implementation.
Phase 3: Evaluation and Implementation of the New Digital Tank
One of our community hospitals served as a pilot site for the new digital tanks. We visited the site and conducted a heuristic evaluation of the new oxygen tank. The new tanks have several design features that would prevent potential errors, such as a visual digital display to show the remaining volume in number, a volume bar with color coding, an automatic calculation of the time remaining based on the flow rate, and auditory warnings when the oxygen tank is low and is at risk of running out within 15 minutes.
During the evaluation, we also identified some potential system barriers. For example, the icon to indicate an almost empty tank may be confusing and be interpreted by different users with different meanings. The interface showing the time remaining lacks a unit which may cause user confusion. The findings informed the sociotechnical system solutions during the implementation process.
In conclusion, RCAs or PRAs are opportunities for human factors engineering to contribute with a work system evaluation, which may result in positive system changes. The Human Factors studies may not end at the time of finishing the RCA or PRA. It may last for a few years to continuously identify the system barriers throughout the implementation process (for both short-term and long-term solutions). With a systems perspective in mind, we may design a robust and resilient system that truly addresses the system barriers/vulnerabilities to make it harder for an error to occur.
Event Type
Oral Presentations
TimeWednesday, April 210:30am - 10:52am EDT
LocationHarbour C
Hospital Environments (HE)