A human factors approach to quality improvement in oxygen prescribing

Alastair Watson; Rahul Mukherjee; Dominic Furniss; Jane Higgs; Alastair Williamson; Alice Turner

doi:10.7861/clinmed.2021-0164

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Fig 1.
FRAM framework
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Fig 2.
FRAM network diagram of oxygen prescribing and administration. Haemo = haematology; obs = observations; onc = oncology.
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Fig 3.
Oxygen prescription in COPD patients at Heartlands Hospital. The SPC chart shows upper and lower control limits (UCL and LCL, respectively). The following interventions are indicated. 1 = addition of oxygen session to junior doctor training (April 2018 and April 2019). 2 = regular face-to-face training of ward nurses by clinical nurse specialist (May to June 2018 and July 2019). 3 = posters pertaining to oxygen prescription on wards (September 2018 and September 2019. 4 = introduction of National Early Warning Score 2 (NEWS2) chart, and electronic training set up (e-learning) (December 2018). 5 = informative screensavers (September 2019). FRAM = FRAM data collection and analysis.

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Table 1.

Key themes identified through FRAM analysis, aspect of functions which these relate to, and traditional and new interventions which were identified through FRAM analysis and considering these aspects

Findings/quotation	Related FRAM aspect(s)	Traditional interventions	New interventions identified through FRAM analysis
Prescribing was done for convenience rather than need ‘We prescribe all the oxygen categories available on the EPS [electronic prescribing system] so that whatever the patient needs, it's covered. Patient need is so variable that it doesn't make sense to be too precise.’ (Junior doctor)	Control	Electronic observation charts with reminders based on observed data^a	Automatic prompt within EPS on prescription type based on history and observations, to encourage healthcare professionals to think about what oxygen to prescribe and why, rather than prescribing all the different types^b Involvement of pharmacy team as part of drug reviews to add an extra layer of control and review^b
Knowledge of harms of oxygen was variable	Outcome	Education of medical and nursing staff, via formal e-learning and face-to-face methods, as well as informal reminders on ward^a	Screensavers about safe oxygen use to remind healthcare professionals what outcomes we are trying to achieve and what we are trying to avoid^a
Oxygen was readily available, so prescribing did not influence receipt ‘Nurses give oxygen before the patient's been seen by a doctor – it's not practical to wait for a doctor. And doctors would think they [nurses] were mad for bleeping them to come and prescribe oxygen !’ (Nurse)	Resources; time		Reminders next to oxygen ports on wall^b Highlighting to staff within the Trust cost savings programme^b
Cost of oxygen was not something staff thought much about
Responsibility for oxygen seemed to fall between nurses and doctors, with each perceiving some level of responsibility for the other staff group ‘The most important thing is that the nurses and doctors discuss the patient's oxygen needs – putting the prescription on the EPS doesn't really help or mean anything.’ (Nurse)	Precondition	Education, as above^a	Implementation of ward round checklist to have a regular review of what oxygen is/is not prescribed and the target saturations^b Implementing Trust QI leadership standards to promote an MDT approach, encourage conversations between groups and promote all members to effect positive change of organisational cultures and microcultures, to facilitate improvement in safe oxygen administration^b
Giving oxygen is more important than prescribing it See quote given under ‘Precondition’	Input	Education, as above^a Posters pertaining to oxygen prescription to remind staff^a
Prescribing practices focused on saving staff time ‘I just prescribe oxygen for every patient I clerk, even if they don't seem like they're going to need it. Then it's on there if they do need it.’ (Junior doctor)	Time	Education as above^a	Guidance within EPS on prescription type^b Staffing level review^b

Aspects are related to individual FRAM functions, as seen within the network diagram where the full breakdown and network can be seen (Fig 1). However, to simplify reporting, we have extrapolated findings up to consider the singular system function within this table.
↵^aIntervention implemented during project.
↵^bFuture and potential interventions.