The Pennsylvania Patient Safety Reporting System (PA-PSRS, pronounced "PAY-sirs") is a confidential, statewide reporting system on the Internet to which all hospitals, outpatient-surgery facilities, and birthing centers, as well as some abortion facilities, must file information on medical errors.
Safety Monitor, this column in AJN from PA-PSRS, serves to inform nurses on issues that can affect patient safety and presents strategies they can integrate easily into practice.
For more information on PA-PSRS, visit the Web site of Pennsylvania's Patient Safety Authority, at http://www.psa.state.pa.us. For the original articles discussed in this column or for other articles on patient safety, click on "Advisories and Related Resources" in the left-hand navigation menu.
Urgency often trumps attention to detail in the transport of hospitalized patients. One frequent consequence is the disruption of supplemental oxygen. Even a small change in the amount of oxygen provided to a compromised patient can radically reduce arterial oxygen saturation. As the following PA-PSRS reports indicate, breakdowns in providing oxygen occur when the physician's orders are not followed, the source of oxygen isn't turned on, the cylinder becomes empty, the oxygen tubing isn't connected, or the delivery device isn't appropriately placed on the patient.
* After returning a patient from physical therapy, a transport aide reported to the floor nurse that oxygen and pulse oximetry had been provided during physical therapy but that, during transport, the alarm on the pulse oximeter had sounded. The patient's oxygen saturation was 85%. It was discovered that the oxygen canister was turned off.
* When a patient arrived at the operating room holding area for surgery, the oxygen cylinder was empty and the patient's oxygen saturation was 70%.
* A mechanically ventilated patient was transported from the ICU to a cardiac catheterization lab for an emergency procedure. After being placed on a ventilator by a respiratory therapist, the patient appeared to be "bucking the vent" and went into respiratory distress. Although the ventilator was connected to the oxygen tubing, the oxygen hadn't been turned on.
WHAT YOU CAN DO
Standardization of tasks involving supplemental oxygen can help reduce disruptions in oxygen delivery during patient transfers. A formal, systematic hand-off approach with delineated responsibilities and a trail of accountability can provide the structure to reinforce essential steps in the transfer process.
A transfer form that includes patient-specific details and the available minutes of oxygen in the portable oxygen cylinder provides both a consistent reminder and a means of communication. The form can also include the ordered amount of oxygen and the name of the patient's nurse in the event contact is needed while the patient is off the unit. This provides both the transport aide and the staff member receiving the patient limited but essential information.
There are multiple steps to follow when disconnecting the patient's oxygen tubing from the wall outlet in order to ensure that the patient receives supplemental oxygen during transport. The omission of any one of these steps will prevent the delivery of oxygen. The following mnemonic, S-T-A-R-T, can be used to eliminate reliance solely on memory:
* Supply enough oxygen for the trip
* Turn on the oxygen cylinder
* Apply the cannula
* Rate as ordered
* Trace the connections
Be aware that oxygen tanks often become depleted during transport, especially if there are unforeseen delays. A table like the one on this page, which gives the estimated minutes of available oxygen according to the amount of oxygen in the cylinder (measured in pounds per square inch, gauge [psig]) and the number of liters per minute prescribed for the patient, can help to determine whether the supply is adequate for the planned trip.1 A pulmonary clinical nurse specialist at a Veterans Administration hospital developed the table, which can be posted in oxygen cylinder storage areas or attached to the cylinders themselves to help transporters identify "at risk" levels of oxygen, as identified by the shaded areas in the table.
But even with the best of planning, oxygen can run out. Oxygen cylinders should be stored in strategically chosen locations throughout the facility and regularly maintained.
This table is for use only with E cylinders.
Shaded area indicates "at-risk" minutes. Times may vary; consult a respiratory therapist to confirm.
Instructions for using the table (all transport staff should be trained in its use):
* Read the pressure (measured in psig, or pounds per square inch, gauge) of the E cylinder, and round the pressure reading down.
* When the pressure in the cylinder is between two psig values given in the table, use the column with the lower value to determine the approximate minutes of oxygen available. For example, if the gauge shows 1,100 psig, use the column under 1,000.
* In the left-hand column, locate the number of liters per minute indicated for the patient.
* Find the intersection of the row for the prescribed liters and the column under the psig now in the cylinder. The box in which they intersect gives the approximate number of minutes of oxygen left in the cylinder for this patient.
Here's an example: The patient is prescribed 5 L of oxygen per minute. The pressure on the gauge of the oxygen tank is 1,600 psig. The intersection of the pressure value column (1,500 psig, the lower value) and the delivery rate row (5 L per minute) shows that the oxygen cylinder has 84 minutes of oxygen remaining for the patient's use.
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