Proposed Topic (Most preferred): :
Clinical Safety and Quality Service II (Projects aiming to enhance clinical safety and outcomes, clinical governance / risk management)
Proposed Topic (Second preferred): :
HA Young Investigators Session (Projects to be presented by HA staff who had joined HA for 10 years or less)
Authors (including presenting author) :
SO KF, NG CF, CHEUNG TP, TSANG LF, TANG SK
Affiliation :
Nursing Services Division, United Christian Hospital
Introduction :
Recent incidents involving the operation of oxygen cylinders in different hospitals have underscored a critical need for enhancing safety protocols. These incidents have heightened the risk of adverse patient outcomes and illuminated gaps in staff knowledge and procedural adherence. Such events necessitate a rigorous evaluation of current practices and the implementation of targeted strategies to mitigate risks associated with oxygen therapy. This project was initiated in response to this emergent challenge, with the goal of fortifying patient safety through improved utilization of oxygen cylinders.
Objectives :
To implement strategic interventions to enhance the safety and competency of nursing staff in operating oxygen cylinders.
Methodology :
1. Incident Sharing: Analysis of reported incidents involving oxygen cylinders was conducted and findings were shared in various departmental meetings to raise awareness and identify areas for improvement. 2. Supplier Engagement: Feedback and suggestions were communicated to the oxygen cylinder supplier to consider design modifications that could enhance safety and usability. 3. Educational Video: In phase 1, a 3-minute instructional video was produced and hosted to the e-Learning center (eLC) to demonstrate proper operation procedures for FX oxygen cylinders. In phase 2, a 4-minute instructional video was produced involving FX and other conventional types of oxygen cylinders, emphasizing safe oxygen cylinder 3-2-1. The video serves as an ongoing educational resource for current nurses and future inductees. 4. Audit Implementation and Execution: An audit form was meticulously designed to facilitate the consistent evaluation of compliance with oxygen cylinder handling protocols. Beyond the design, a hospital-wide, unit-based audit was executed from 15 Dec 2023 to 31 Jan 2024, engaging nurses across various departments to systematically review practices and adhere to safety standards. 5. Collaborative Drills: Engagement with different departments was initiated to incorporate oxygen cylinder usage into departmental cardiopulmonary (CPR) drills.
Result & Outcome :
The audit has involved 1019 nurses. Results are promising, with a 99.95% compliance rate achieved. No incidents related to the operation of oxygen cylinders were reported. As of 04 Mar 2024, the two e-courseware have been accessed by 1.844 staff, which includes nursing staff, temporary undergraduate nursing students (TUNS), allied health professionals and supporting staff. Our quality improvement initiative has significantly elevated the safe operation of oxygen cylinders through a cohesive strategy encompassing incident analysis, educational reinforcement, and comprehensive auditing. These efforts have reduced the frequency of oxygen-related incidents and cultivated an environment of continuous learning and vigilance, ultimately enhancing patient safety and care quality.
