Safety

SIDE RAILS

ARE THE MOST COMMON PHYSICAL RESTRAINT (3 up not 4. 4 is considered a physical restraint)

Factors in a patient's environment that decrease the amount of available oxygen

A common environmental hazard in the home is an improperly functioning heating system. A furnace, stove, or fireplace that is not properly vented introduces carbon monoxide into the environment (NFPA, 2014a).

Product or Device Events (NQF SRE's)

A. Patient death or serious disability associated with use of contaminated drugs, devices, or biologicals provided by the health care facility B. Patient death or serious disability associated with use or function of a device in patient care when the device is used for functions other than as intended C. Patient death or serious disability associated with intravascular air embolism that occurs during care in a health care facility

Surgical Events (NQF SRE's)

A. Surgery performed on the wrong body part B. Surgery performed on the wrong patient C. Wrong surgical procedure performed on a patient D. Unintended retention of foreign object in a patient after surgery or procedure E. Intraoperative or immediately postoperative death

Carbon monoxide

affects a person's oxygenation by binding with hemoglobin, preventing the formation of oxyhemoglobin and thus reducing the supply of oxygen delivered to tissues (see Chapter 41). Low concentrations cause nausea, dizziness, headache, and fatigue. Very high concentrations cause death after 1 to 3 minutes of exposure (Mayo Clinic, 2014).

Fear of falling

is a concern of community-dwelling older adults, and many avoid activities because of their fear.

pollutant

is a harmful chemical or waste material discharged into the water, soil, or air.

SPLATT

• Symptoms at time of fall • Previous fall •Location of fall • Activity at time of fall • Time of fall • Trauma after fall

Resources Related to Safety and Safety Initiatives

-The Joint Commission http://www.jointcommission.org/ -The Agency for Healthcare Research and Quality http://www.ahrq. gov/ -The Institute for Healthcare Improvement http://www.ihi.org/ - The U.S. Department of Veterans Affairs http://www.patientsafety.va.gov - Centers for Medicare and Medicaid Services http://www.cms.gov -ECRI Institute http://www.ecri.org -U.S. Department of Health and Human Services http://www.hospitalcompare.hhs.gov

the risk of motor vehicle accidents is higher among

16- to 19-year-old drivers than any other age-group. Teens are more likely to underestimate dangerous situations or not be able to recognize hazardous situations, speed and allow shorter headways, ride with intoxicated drivers, and drive after using alcohol and drugs. Teens also have the lowest rate of seat belt use.

Impaired Mobility

A patient with impaired mobility has many kinds of safety risks. Muscle weakness, paralysis, and poor coordination or balance are major factors in falls. Immobilization predisposes patients to additional physiological and emotional hazards, which in turn further restrict mobility and independence. People who are physically challenged are at greater risk for injury when entering motor vehicles and buildings that are not handicap accessible.

Environmental Safety

A patient's environment includes physical and psychosocial factors that influence or affect the life and survival of that patient. This broad definition of environment crosses the continuum of care for settings in which the nurse and patient interact such as the hospital, long-term care facility, clinic, community center, school, and home. A safe environment protects the staff as well, allowing them to function optimally.

SBAR

A standard approach to communication,(Situation, Background, Assessment, Recommendation) helps you obtain and organize information .

Criminal Events (NQF SRE'S)

A. Care provided by someone impersonating a health care provider B. Abduction of patient of any age C. Sexual assault on patient within or on the grounds of a health care facility D. Death or significant injury resulting from a physical assault that occurs within or on the grounds of the facility

Patient-Protection Events(NQF SRE's)

A. Infant discharged to wrong person B. Patient death or serious disability associated with patient elopement C. Patient suicide or attempted suicide resulting in serious disability during care in a health care facility

Environmental Events (NQF SRE's)

A. Patient death or serious disability associated with an electric shock during care in a health care facility B. Any incident in which a line designated for oxygen or other gas to be delivered to a patient contains the wrong gas or is contaminated by toxic substances C. Patient death or serious disability associated with burn incurred from any source during care in a health care facility D. Patient death or serious disability associated with fall during care in a health care facility E. Patient death or serious disability associated with use of restraints or bed-rails during care in a health care facility

Care-Management Events(NQF SRE'S)

A. Patient death or serious disability associated with medication error B. Patient death or serious disability associated with hemolytic reaction as a result of administration of ABO/HLA-incompatible blood or blood products C. Maternal death or serious disability associated with labor or delivery in a low-risk pregnancy during care in a health care facility D. Patient death or serious disability associated with hypoglycemia, the onset of which occurs during care in a health care facility E. Death or serious disability associated with failure to identify and treat hyperbilirubinemia in neonates F. Stage III or IV pressure ulcers acquired after admission to a health care facility G. Patient death or serious disability caused by spinal manipulative therapy H. Artificial insemination with wrong donor sperm or wrong egg

Equipment-Related Accidents

Accidents that are equipment related result from the malfunction, disrepair, or misuse of equipment or from an electrical hazard. To avoid rapid infusion of IV fluids, all general-use and patient-controlled analgesic pumps need to have free-flow protection devices. To avoid accidents, do not operate monitoring or therapy equipment without adequate instruction. If you find a piece of faulty equipment, place a tag on it to prevent it from being used on another patient and promptly report any malfunctions. Assess potential electrical hazards to reduce the risk of electrical fires, electrocution, or injury from faulty equipment. In health care settings the clinical engineering staff make regular safety checks of equipment. Facilities must report all suspected medical device-related deaths to both the FDA and the manufacturer of the product if known (USFDA, 2015). This is usually done in conjunction with the risk-management department after tagging and removing the piece of equipment.

Adolescent (risk at developmental stage)

Adolescents develop greater independence and begin to develop a sense of identity and their own values. The adolescent begins to separate emotionally from his or her family, and peers generally have a stronger influence. Wide variations that swing from childlike to mature behavior are characteristic of adolescent behavior (Hockenberry and Wilson, 2015). In an attempt to relieve the tensions associated with physical and psychosocial changes and peer pressures, some adolescents engage in risk-taking behaviors such as smoking, drinking alcohol, and using drugs. This increases the incidence of accidents such as drowning and motor vehicle accidents. When adolescents learn to drive, their environment expands, and so does their potential for injury. Teen motor vehicle crashes are preventable by avoiding distractions such as using cell phones, texting, eating, and drinking while driving. To assess for possible substance abuse, have parents look for environmental and psychosocial clues from their children. Environmental clues include the presence of drug-oriented magazines, beer and liquor bottles, drug paraphernalia and blood spots on clothing, and the continual wearing of long-sleeved shirts in hot weather and dark glasses indoors. Psychosocial clues include failing grades, change in dress, increased absenteeism from school, isolation, increased aggressiveness, and changes in interpersonal relationships. Because adolescence is a time when mature sexual physical characteristics develop, some adolescents begin to have physical relationships with others that present the risk of sexually transmitted infections.

Types of pollution

Air pollution is the contamination of the atmosphere with a harmful chemical. Prolonged exposure to industrial waste and vehicle exhaust increases the risk of pulmonary disease. In the home, school, or workplace, cigarette smoke is the primary cause of air pollution. Improper disposal of radioactive and bioactive waste products (e.g., dioxin) can cause land pollution. Water pollution is the contamination of lakes, rivers, and streams, usually by industrial pollutants. If water becomes contaminated, the public needs to use bottled or boiled water for drinking and cooking. Flooding damages water-treatment stations and also requires the use of bottled or boiled water.

Pulling a fire alarm

Always protect your patient and provide safety before pulling a fire alarm. (PT safety always comes first)

RISK FOR FALLS assessment

At a minimum the assessment needs to be completed on admission, following a change in a patient's condition, after a fall, and when transferred. If it is determined that a patient is at risk for falling, regular assessment always continues. In many cases family members are important resources in assessing a patient's fall risk.

Sensory or Communication Impairment

Cognitive impairments associated with delirium, dementia, and depression contribute to altered concentration and attention span, impaired memory, and orientation changes. Patients with these alterations become easily confused about their surroundings and are more likely to have falls and burns. Patients with visual, hearing, tactile, or communication impairment such as aphasia or a language barrier are not always able to perceive a potential danger or express their need for assistance

Implementation (step 4 of nursing process)

Direct your nursing interventions toward maintaining a patient's safety in all types of settings. You implement health promotion and illness prevention measures in the community setting, whereas prevention is a priority in the acute care setting.

hypothermia

Exposure to severe cold for prolonged periods causes frostbite and accidental hypothermia. Older adults, the young, patients with cardiovascular conditions, patients who have ingested drugs or alcohol in excess, and people who are homeless are at high risk for hypothermia.

Diagnosis (step 2 of nursing process)

Gather data from your nursing assessment and analyze clusters of defining characteristics or risk factors to identify relevant nursing diagnoses. Include specific related or contributing factors to individualize your nursing care (Box 27-6). For example, the nursing diagnosis "Risk for Falls" is associated with altered mobility or sensory alteration (e.g., visual) risk factors. Altered mobility leads you to select such nursing interventions as range-of-motion (ROM) exercises; more frequent supervised ambulation; or teaching the proper use of safety devices such as side rails, canes, or crutches.

Infant, Toddler, and Preschooler (INTERVENTION)

Growing, curious children need adults to protect them from injury. Children are trusting of their environment and do not perceive themselves to be in danger. Educate parents or guardians about reducing risks of injuries to children and ways to promote safety in the home (Table 27-1). Nurses working in prenatal and postpartum settings easily incorporate safety into the care plans of childbearing families. Community health nurses assess the home and show parents how to promote safety. Educate parents about the importance of immunizations and how they protect a child from life-threatening disease.

Example of a intervention to promote safety for an INFANT

Have infants sleep on their back or side. Teach parents the mnemonic "back to sleep." Rationale **Placing infants on their back confers the lowest risk of sudden infant death syndrome (SIDS) and is the preferred position

long-term care settings

Informed consent from family members is required before using restraints

Infant, Toddler, and Preschooler(risk at developmental stage)

Injuries are the leading cause of death in children over age 1 and cause more death and disabilities than do all diseases combined (Hockenberry and Wilson, 2015). The nature of the injury sustained is closely related to normal growth and development. For example, the incidence of lead poisoning is highest in late infancy and toddlerhood. Children at this stage explore the environment and, because of their increased level of oral activity, put objects in their mouths. This increases risk for poisoning and choking. Fire often results from their curiosity in playing with matches. In addition, limited physical coordination contributes to falls from bicycles and playground equipment. Additional injuries at this age are related to riding unrestrained in a motor vehicle, drowning, and head trauma from objects. Accidents involving children are largely preventable, but parents need to be aware of specific dangers at each stage of growth and development. Thus accident prevention requires health education for parents and the removal of dangers whenever possible.

Posey bed

It is a soft-sided, self-contained enclosed bed that is much less restrictive than chemical or physical restraints. It allows for freedom of movement and thus reduces the side effects such as pressure ulcers and loss of dignity caused by physical restraints. A vinyl top covers the padded upper frame of the bed, and the nylon-net canopy surrounds the mattress and completely encloses the patient in the bed. Zippers on the four sides of the enclosure provide access to the patient. The Posey bed enclosure works well for patients who are restless and unpredictable, cognitively impaired, and at risk for injury if they were to fall or get out of bed such as patients on anticoagulant therapy at risk for intracranial bleed. The bed is also a safer alternative to side rails.

Older Adult

Nursing interventions for older adults reduce patients' risks of falls and other accidents and compensate for the physiological changes of aging. Provide information about neighborhood resources to help an older adult maintain an independent lifestyle. Older adults frequently relocate to new neighborhoods and need to become acquainted with new resources such as modes of transportation, church schedules, and food resources (e.g., Meals on Wheels).

Evaluation (step 5 of nursing process)

Patient-centered care involves a thorough evaluation of a patient's perspective related to safety and whether his or her expectations have been met. **involves monitoring the actual care delivered by the health care team on the basis of the expected outcomes (Figure 27-10). For each nursing diagnosis measure whether the outcomes of care have been met. If your patient meets the goals, the diagnosis is resolved, and your nursing interventions were effective and appropriate. If not, determine whether new safety risks to the patient have developed or whether previous risks remain.

Planning (step 3 of nursing process)

Patients with actual or potential risks to safety require a nursing care plan with interventions that prevent and minimize threats to their safety. Design your interventions to help a patient feel safe to move about and interact freely within the environment. The total plan of care addresses all aspects of patient needs and uses resources of the health care team and the community when appropriate. Critically synthesize information from multiple sources (Figure 27-3). Critical thinking ensures that a patient's plan of care integrates all that you learned about the patient and the key critical thinking elements. For example, you reflect on knowledge regarding the services that other health professions (e.g., occupational therapy, case management) provide to help patients return to their home environments safely.**INVOLVE PATIENT IN PLANNING

Setting Priorities

Prioritize a patient's nursing diagnoses and interventions to provide safe and efficient care.Plan individualized interventions on the basis of the severity of risk factors and the patient's developmental stage, level of health, lifestyle, and cultural needs (Box 27-7). Planning involves an understanding of the patient's need to maintain independence within physical and cognitive capabilities. Collaborate to establish ways of maintaining the patient's active involvement within the home and health care environment. Education of the patient and family is also an important intervention to plan for reducing safety risks over the long term.

Adolescent

Risks to the safety of adolescents involve many factors outside the home because much of their time is spent away from home and with their peer group. Adults serve as role models for adolescents and, by providing examples, setting expectations, and providing education, help them minimize risks to their safety. This age-group has a high incidence of suicide because of feelings of decreased self-worth and hopelessness. Be aware of the risks posed at this time and be prepared to teach adolescents and their parents measures to prevent accidents and injury.

Adult.

Risks to young and middle-age adults frequently result from lifestyle factors such as childrearing, high stress levels, inadequate nutrition, use of firearms, excessive alcohol intake, and substance abuse (see Chapter 13). In this fast-paced society there also appears to be more expression of anger, which can quickly precipitate accidents related to "road rage." Help adults understand their safety risks and guide them in making lifestyle modifications by referring them to resources such as classes to help quit smoking and for stress management, including employee-assistance programs. Also encourage adults to exercise regularly, maintain a healthy diet, practice relaxation techniques, and get adequate sleep.

Lifestyle

Some lifestyle choices increase safety risks. People who drive or operate machinery while under the influence of chemical substances (drugs or alcohol), work at inherently dangerous jobs, or are risk takers are at greater risk of injury. In addition, people experiencing stress, anxiety, fatigue, or alcohol or drug withdrawal or those taking prescribed medications are sometimes more accident prone. Because of these factors, some people are too preoccupied to notice the source of potential accidents such as cluttered stairs or a stop sign.

Lack of Safety Awareness

Some patients are unaware of safety precautions such as keeping medicine or poisons away from children or reading the expiration date on food products. A nursing assessment that includes a home inspection helps you identify a patient's level of knowledge about home safety so you can correct deficiencies with an individualized nursing care plan.

Oxygen regulations

Strict codes regulate the use and storage of medical oxygen in health care facilities. This is not necessarily true in the home environment. Hospital emergency departments see approximately 1190 thermal burns per year caused by ignitions associated with home medical oxygen (NFPA, 2008).

Example of a Preschoolers intervention to promote safety

Teach children to swim at an early age but always provide supervision near water. Rationale **Learning to swim is a useful skill that can someday save a child's life. However, all children need constant supervision.

patient-centered care

The IOM defined patient-centered care as health care that establishes a partnership among practitioners, patients, and their families (when appropriate) to ensure that decisions respect patients' wants, needs, and preferences and that patients have the education and support they need to make decisions and participate in their own care (IOM, 2001). Considerable emphasis is placed on improving the education of nursing students so they become competent in promoting safe health care practices.

Older Adult (risk at developmental stage)

The physiological changes associated with aging, effects of multiple medications, psychological and cognitive factors, and the effects of acute or chronic disease increase an older adult's risk for falls and other types of accidents. The risk of being seriously injured in a fall increases with age. Patients who wander have special safety challenges.

Adult (risk at developmental stage)

The threats to an adult's safety are frequently related to lifestyle habits. For example, a person who uses alcohol excessively is at greater risk for motor vehicle accidents. People who smoke long-term have a greater risk of cardiovascular or pulmonary disease as a result of the inhalation of smoke and the effect of nicotine on the circulatory system. Likewise, the adult experiencing a high level of stress is more likely to have an accident or illness such as headaches, gastrointestinal (GI) disorders, and infections. Older Adult.

Place patients of ANY AGE at risk of falling

The unfamiliar environment, effects of acute illness or surgery, impaired mobility, effects of medications and treatments, and placement of various tubes and catheters

Spread of pathogens poses a risk to nurse and patient

Therefore always follow standard and transmission-based isolation precautions and use proper hand hygiene

Health Promotion

To promote an individual's health, it is necessary for the individual to be in a safe environment and practice a lifestyle that minimizes risk of injury.

Radiation

To reduce your exposure to radiation, limit the time spent near the source, make the distance from the source as great as possible, and use shielding devices such as lead aprons. Staff who work regularly near radiation wear devices that track the accumulative exposure to radiation.

School-Age Child (risk at developmental stage)

When a child enters school, the environment expands to include the school, transportation to and from school, school friends, and after-school activities. School-age children are learning how to perform more complicated motor activities and often are uncoordinated. Parents, teachers, and nurses need to instruct children in safe practices to follow at school or play, including what to do if approached by strangers. Teach school-age children involved in team and contact sports the rules for playing safely and how to use protective safety equipment such as helmets and other protective gear. Head injuries are a major cause of death, with bicycle accidents being one of the major causes of such injuries (Hockenberry and Wilson, 2015). Bikes need to be the proper size for the child, and helmets must be worn (Figure 27-1). Parents need to be reminded of the importance of a helmet for tricycles, scooters, and motorized toys. Additional injuries in this age-group are decreased by using seat belts and booster seats in motor vehicles properly and providing pedestrian safety education.

Goals and Outcomes (planning)

You collaborate with a patient, family, and other members of the health care team when setting goals and expected outcomes during the planning process (see the Nursing Care Plan). The patient who actively participates in reducing threats to safety becomes more alert to potential hazards and is more likely to adhere to the plan. Make sure that goals and outcomes for each nursing diagnosis are measurable and realistic, with consideration of the resources available to the patient. For example, in the case of the nursing diagnosis of Impaired Physical Mobility related to left-sided paralysis, the goal is the patient "will remain free of injury throughout hospitalization." Examples of expected outcomes include: • Patient uses tripod cane correctly within 24 hours. • Patient describes approach to rise up from bed correctly with assistance by end of the teaching session today.

When caring for a patient in the home

a home hazard assessment is necessary. A thorough hazard assessment covers topics such as adequacy of lighting (inside and outdoors), presence of safety devices, placement of furniture or other items that can create barriers, condition of flooring, and safety in the kitchen and bathrooms. Know where medications and cleaning supplies are located. Walk through the home with the patient and discuss how he or she normally conducts daily activities and whether the environment poses problems. Assess for the presence of locks on doors and windows that make the home less susceptible to intruders. When assessing the adequacy of lighting, inspect the areas where the patient moves and works such as outside walkways, steps, interior halls, and doorways. Getting a sense of a patient's routines helps you recognize less obvious hazards.

NQF endorsed

a select list of serious reportable events (SREs), which was updated in 2006. The 28 events (Box 27-3) are a major focus of health care providers for patient safety initiatives.

Patient-Inherent Accidents

accidents (other than falls) in which a patient is the primary reason for the accident. Examples include self-inflicted cuts, injuries, and burns; ingestion or injection of foreign substances; self-mutilation or fire setting; and pinching fingers in drawers or doors. One of the more common precipitating factors for a patient-inherent accident is a SEIZURE.

Never Events

adverse events that should never occur in a health care setting.(CMS names select SREs as Never Events ). The CMS (2015) denies hospitals higher payment for any hospital-acquired condition resulting from or complicated by the occurrence of certain Never Events (Box 27-4).

Main risk factors for developing fear of falling

are at least one fall, being female, and being older

Procedure-Related Accidents

are caused by health care providers and include medication and fluid administration errors, improper application of external devices, and accidents related to improper performance of procedures such as dressing changes or urinary catheter insertion. Nurses are able to prevent many procedure-related accidents by adhering to organizational policy and procedures and standards of nursing practice. For example, proper preparation and administration of medications, use of patient and medication bar coding, and "smart" intravenous (IV) pumps reduce medication errors

Older drivers

are keeping their licenses longer and driving more miles than in the past. Per mile traveled, fatal crash rates increase starting at age 75 and5 ncrease markedly after age 80 (Insurance Institute for Highway Safety, 2015). An older adult is not always able to quickly observe situations in which an accident is likely to occur. Decreased hearing acuity alters the ability to hear emergency vehicle sirens or vehicle horns. A decreased nervous system response prevents older adults from being able to react as quickly as they once could to avoid an accident. A decline in these skills accounts for the most common types of accidents, including right-of-way and turning accidents.

Fetuses, infants, and children

are more vulnerable to lead poisoning than adults because their bodies absorb lead more easily and small children are more sensitive to the damaging effects of lead. Exposure to excessive levels of lead affects a child's growth or causes learning and behavioral problems and brain and kidney damage

fall or stage III pressure ulcer

are nurse-sensitive indicators, meaning that a nurse directly affects their development.

The National Patient Safety Goals of TJC (2016)

are specifically directed to reduce the risk of medical errors (Box 27-2). The goals highlight specific improvements in patient safety and ongoing problematic areas in health care. These evidence-based recommendations require health care facilities to focus their attention on a series of specific actions. The Joint Commission 2015 National Patient Safety Goals for Critical Access Hospitals (box 27-2) -Identify patients correctly. - Improve staff communication. -Use medicines safely. -Use alarms safely. - Prevent infection. -Prevent mistakes in surgery.

patient falls with injury, incidence of pressure ulcers, and central line bloodstream infection

are standards for judging the quality of care of health care organizations (NQF,CMS, TJC measures of patient safety)

Unintentional injuries

are the fifth leading cause of death for Americans of all ages (National Center for Injury Prevention and Control, 2010a, 2010b).

Motor vehicle accidents

are the leading cause, followed by poisonings and falls.

Active strategies

are those in which an individual is actively involved through changes in lifestyle (e.g., engaging in better nutritional health or exercise programs, wearing seat belts) and participation in wellness programs.

A physician's order is required for restraints

based on a face-to-face assessment of the patient. The order must be current, state the type and location of restraint, and specify the duration and circumstances under which it will be used. These orders need to be renewed within a specific time frame according to the policy of the agency. In hospital settings each original restraint order and renewal is limited to 8 hours for adults, 2 hours for ages 9 through 17, and 1 hour for children under age 9 (TJC, 2015). Restraints are not to be ordered prn (as needed).

Environmental factors that contribute to FALLS

broken stairs, icy sidewalks, inadequate lighting, throw rugs, and exposed electrical cords cause many of the accidents.

Falls can be decreased by

by group exercise, tai chi, and having cataract surgery. Decreasing hazards in the home that increase falls is also effective.

The leading cause of fire-related death is

careless smoking, especially when people smoke in bed at home.

Exposure to extreme heat

changes the electrolyte balance of the body and raises the core body temperature, resulting in heatstroke or heat exhaustion. Chronically ill patients, older adults, and infants are at greatest risk for injury from extreme heat. These patients need to avoid extremely hot, humid environments (see Chapter 30).

Temperature extremes that frequently occur during the winter and summer affect

comfort, productivity, and safety.

A patient's developmental stage

creates threats to safety as a result of lifestyle, cognitive and mobility status, sensory impairments, and safety awareness. With this information you tailor safety prevention programs to the needs, preferences, and life circumstances of particular age-groups. Unfortunately all age-groups are subject to abuse. Child abuse, domestic violence, and elder abuse are serious threats to safety

Interventions shown to reduce hospital fall rates include

developing a culture of safety, conducting fall risk assessments, and multifactorial interventions (e.g., equipment upgrades, removing hazards, identifying high-risk patients, low beds).

All staff need to be aware that

distractions and interruptions contribute to procedure-related accidents and need to be limited, especially during high-risk procedures such as medication administration.

Nurses role in preventing physical hazards

educating patients about common safety hazards and how to prevent injury while placing emphasis on hazards to which patients are more vulnerable.

Seizure precautions

encompass all nursing interventions to protect a patient from traumatic injury, position for adequate ventilation and drainage of oral secretions, and provide privacy and support following the seizure (Box 27-14).

The Joint Commission (TJC) and the Centers for Medicare and Medicaid Services (CMS) emphasize

error prevention and patient safety. Their "Speak Up" campaign encourages patients to take a role in preventing health care errors by becoming active, involved, and informed participants on the health care team. For example, patients are encouraged to ask health care workers if they have washed their hands before providing care.

Nurses face specific environmental risks

exposure to various forms of chemicals. Chemicals found in some medications (e.g., chemotherapy), anesthetic gases, cleaning solutions, and disinfectants are potentially toxic if ingested, absorbed into the skin, or inhaled.

Injuries from falls often

extend a patient's length of stay in the health care environment, placing them at an even greater risk for other complications.

Older patients are more likely to

fall in the bedroom, bathroom, and kitchen in their homes.

Among adults 65 years and older

falls are the leading cause of both fatal and nonfatal injuries

RISKS to a patient's safety within the health care environment include

falls, patient-inherent accidents, procedure-related accidents, and equipment-related accidents. The nurse assesses for these four potential problem areas and, considering the developmental level of the patient, takes steps to prevent or minimize accidents.

Health care organizations

foster a patient-centered safety culture by continually focusing on performance-improvement endeavors, risk-management findings, and safety reports; providing current reliable technology; integrating evidence-based practice into procedures; designing a safe work environment and atmosphere; and providing continuing education and access to appropriate resources for staff

Health care providers are at risk

from chemicals such as toxic cleaning agents.

Physical hazards

in the environment threaten a person's safety and often result in physical or psychological injury or death.

Common physical hazards that lead to falls in the home

include inadequate lighting, barriers along normal walking paths and stairways, loose rugs and carpeting, and a lack of safety devices in the home. Falls are also a common problem in health care settings (Spoelstra et al., 2011). Hospitals throughout the country carefully monitor the incidence of falls and fall-related injuries as part of their ongoing performance improvement work.

Restraint alternatives

include more frequent observations, social interaction such as involvement of family during visitation, frequent reorientation, regular exercise, and the introduction of familiar and meaningful stimuli (e.g., involve in hobbies such as knitting or crocheting or looking at family photos) within the environment. These interventions reduce behaviors such as wandering that often lead to restraint use.

Passive strategies

include public health and government legislative interventions (e.g., sanitation and clean water laws)

A fall-reduction program

includes a fall risk assessment of every patient conducted on admission and routinely (see hospital policy) until a patient's discharge. Many health care organizations are implementing hourly rounding to reduce falls (Box 27-12). In addition, most organizations apply yellow color-coded wristbands to patients' wrists to communicate to all health care providers that a patient is a fall risk. In 2008 the American Hospital Association issued an advisory recommending that hospitals standardize wristband colors: red for patient allergies, yellow for fall risk, and purple for do- not-resuscitate preferences (American Hospital Association, 2008).

Nursing History

includes data about a patient's level of wellness to determine if any underlying conditions exist that pose threats to safety. For example, give special attention to assessing a patient's gait, lower-body muscle strength and coordination, and balance by having the patient walk in his or her room.

Factors that increase the risk of falls

including a history of falling, being age 65 or over, reduced vision, orthostatic hypotension, lower-extremity weakness, gait and balance problems, urinary incontinence, improper use of walking aids, and the effects of various medications (e.g., anticonvulsants, diuretics, hypnotics, sedatives, certain analgesics)

Basic Needs (Physiological needs)

including the need for sufficient oxygen, nutrition, and optimum temperature, influence a person's safety. According to Maslow's hierarchy of needs, these basic needs must be met before physical and psychological safety and security can be addressed

School-Age Child

increasingly explore their environment. They have friends outside their immediate neighborhood; and they become more active in school, church, and community activities. The school-age child needs specific teaching regarding safety in school and at play.

Falls are often a combination of

individual and transient risk factors, the physical environment (e.g., poor lighting, high bed position, improper equipment), and the riskiness of a person's behavior (unwilling to call for assistance when getting up)

Vulnerable groups who often require help in achieving a safe environment

infants, children, older adults, the ill, the physically and mentally disabled, the illiterate, and the poor.

The clinical engineering departments of hospitals

inspect biomedical equipment such as hospital beds, infusion pumps, or ventilators regularly. You know that a piece of equipment is safe to use when you see a safety inspection sticker with an expiration date. Decrease the risk for electrical injury and fire by using properly grounded and functional electrical equipment. The ground prong of an electrical outlet carries any stray electrical current back to the ground. Remove equipment that is not in proper working order or that sparks when plugged in for service and notify the appropriate hospital staff.

incident report or occurrence report

is a confidential document that completely describes any patient accident occurring on the premises of a health care agency (see Chapter 23). Reporting allows an organization to identify trends/patterns throughout the facility and areas to improve. Focusing on the root cause of an event instead of the individual involved promotes a "culture of safety" that helps in specifically identifying what contributed to an error.

Food and Drug Administration (FDA)

is a federal agency responsible for the enforcement of federal regulations regarding the manufacture, processing, and distribution of foods, drugs, and cosmetics to protect consumers against the sale of impure or dangerous substances. Although food supply in the United States is one of the safest in the world, about 48 million illnesses occur annually, more than 128,000 people are hospitalized, and 3000 die from foodborne illness (CDC, 2014a). Groups at the highest risk are children, pregnant women, older adults, and people with compromised immune systems. Foods that are inadequately prepared or stored or subject to unsanitary conditions increase a patient's risk for infections and food poisoning.

home accidental poisoning

is a greater risk for toddlers, preschoolers, and young school-age children, who often ingest household cleaning solutions, medications, or personal hygiene products. Emergency treatment is necessary when a person ingests a poisonous substance or comes in contact with a chemical that is absorbed through the skin. In 2014 more than 2000 people a day were seen in emergency departments after a poison incident (CDC, 2014c). A poison control center is the best resource for patients and parents needing information about the treatment of an accidental poisoning.

excessive noise

is also a form of pollution that presents health risks

Bioterrorism

is another cause of disaster. Threats of this type come in the form of biological, chemical, and radiological attacks. Bioterrorism, or the use of biological agents such as anthrax, smallpox, and botulism to create fear or threat, is the most likely form of a terrorist attack to occur (CDC, 2014d).

restraint

is any manual method or physical or mechanical device (such as full set of side rails), material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely (TJC, 2015). Chemical restraints are medications such as anxiolytics and sedatives used to manage a patient's behavior and are not a standard treatment or dosage for the patient's condition. A restraint does not include devices such as orthopedically prescribed devices, surgical dressings or bandages, protective helmets, or other methods that involve physically holding a patient to conduct routine physical examinations or tests, protecting the patient from falling out of bed, or permitting the patient to participate in activities without the risk of physical harm

pathogen

is any microorganism capable of producing an illness. The most common means of transmission of pathogens is by the hands.

poison

is any substance that impairs health or destroys life when ingested, inhaled, or absorbed by the body. Almost any substance is poisonous if too much is taken. Sources in a person's home include drugs, medicines, other solid and liquid substances, and gases and vapors. Poisons often impair the function of every major organ system.

The QSEN safety competency for a nurse

is defined as "Minimizes risk of harm to patients and providers through both system effectiveness and individual performance." As a nurse you are responsible for incorporating critical thinking skills when using the nursing process, assessing each patient and his or her environment for hazards that threaten safety, and planning and intervening appropriately to maintain a safe environment. By doing this you become a provider of safe acute, restorative, and continuing care and an active participant in health promotion.

seizure

is hyperexcitation and disorderly discharge of neurons in the brain leading to a sudden, violent, involuntary series of muscle contractions that is paroxysmal and episodic, causing loss of consciousness, falling, tonicity (rigidity of muscles), and clonicity (jerking of muscles). A generalized tonic-clonic, or grand mal, seizure lasts approximately 2 minutes (no longer than 5) and is characterized by a cry and loss of consciousness with falling, tonicity, clonicity, and incontinence. During a fall or as a result of muscle jerking, musculoskeletal injuries can occur. Before a convulsive episode a few patients report an aura, which serves as a warning or sense that a seizure is about to occur.

aura

is often a bright light, smell, or taste.

Smoking

is the leading cause of burns, reported fires, deaths, and injuries involving home medical oxygen.

Wandering

is the meandering, aimless, or repetitive locomotion that exposes a person to harm and is often in conflict with boundaries (such as doors), limits, or obstacles (Herdman and Kamitsuru, 2014). Individuals can walk away from home or off care units or enter restricted or closed areas without the knowledge of caregivers. This is a common problem in patients who are confused or disoriented. Interrupting a wandering patient can increase his or her distress.

Person's temperature comfort zone

is usually between 18.3° and 23.9° C (65° and 75° F).

to reduce chances for a medical error

it is essential that you check the patient's identification by using two identifiers (e.g., name and birthday or name and medical record number)

Individual Risk Factors posing threats to safety include

lifestyle, impaired mobility, sensory or communication impairment, and the lack of safety awareness. Know your patients' risks when you plan their nursing care.

The Agency for Healthcare Research and Quality

lists 20 tips to help prevent medical errors

A safe environment includes

meeting basic needs, reducing physical hazards and the transmission of pathogens, and controlling pollution.

Inside falls

most often occur while transferring from beds, chairs, and toilets; getting into or out of bathtubs; tripping over items such as cords covered by rugs or carpets, carpet edges, or doorway thresholds; slipping on wet surfaces; and descending stairs.

Assessment (step 1 of nursing process)

needs to be patient centered and include the patient's own perceptions of his or her risk factors, concerns about being in a health care setting, knowledge of how to adapt to any safety risks, and previous experience with any accidents. To conduct a thorough patient assessment, consider possible threats to the patient's safety, including the immediate environment and any individual risk factors, presents of an underlying illness, identify presents of risk for developmental stage and patient's environment

Often younger patients are not aware

of how medications and treatments cause dizziness, orthostatic hypotension, or changes in balance.

safety

often defined as freedom from psychological and physical injury, is a basic human need.

Lead

older homes in poorer communities continue to contain high lead levels. Soil and water systems are sometimes contaminated. Poisoning occurs from swallowing or inhaling lead.

hand hygiene

one of the most effective methods for limiting the transmission of pathogens is this medically aseptic practice. Hand hygiene is a simple and effective measure to reduce the transmission of pathogens and the risk of subsequent illness.

The Quality and Safety Education for Nurses (QSEN)

project was developed to meet the challenge of preparing future nurses who will have the knowledge, skills, and attitudes necessary to continuously improve the quality and safety of the health care systems within which they work (QSEN, 2014).

Nursing Process

provides a clinical decision-making approach for you to develop and implement an individualized plan of safe patient care. Assessment, Diagnosis, Planning, Implementation, Evaluation

Material safety data sheets (MSDSs)

provides detailed information about the chemical, health hazards imposed, first aid guidelines, and precautions for safe handling and use. MSDSs give information on the steps to take in case the material is released or spilled. Be aware of the location of the MSDSs and be knowledgeable about hazardous chemicals in your environment.

An interdisciplinary approach that includes individualized assessments and development of structured treatment plans

reduces restraint use

safe environment

reduces the risk for illness and injury and helps to contain the cost of health care by preventing extended lengths of treatment and/or hospitalization, improving or maintaining a patient's functional status, and increasing a patient's sense of well-being.

use of safe patient handling techniques and equipment

reduces the risk of injuries when moving and lifting patients

Immunization

reduces, and in some cases prevents, the transmission of disease from person to person. Great progress has been made in the United States over the last 50 years in the use of vaccines to prevent serious and infectious diseases. However, frequently issues about vaccine safety and the increasing complexity of immunization schedules have fostered doubts among parents about the necessity of vaccinations (Kennedy et al., 2011). You are responsible as a nurse to educate parents about the benefits of immunization. A survey conducted in 2010 found that over half of the parents expressed concerns that their child would have a serious reaction from the vaccine or that the vaccine might not be safe. The researchers found that these concerns were predictive of the parents delaying future immunizations for their children (Opel et al., 2013). However, a 2011 survey of over 300 parents found that the majority surveyed reported that they had either already vaccinated (83%) or planned to vaccinate (11%) their children with all recommended vaccines (Kennedy et al., 2011). Lack of immunization puts children and adults at risk.

The Institute of Medicine

reported "To Err Is Human: Building a Safer Health System" (IOM, 2000) was a pivotal publication that brought patient safety to the forefront of health care in the United States. This report indicated that 44,000 to 98,000 people die each year as a result of preventable medical errors. In an effort to improve patient safety, many organizations became devoted to developing and monitoring key health care safety initiatives and providing information to health care organizations and the public.

Falls often lead to

serious injuries such as fractures or internal bleeding. Patients most at risk for injury are those with bleeding tendencies resulting from disease or medical treatments and osteoporosis.

Natural disasters

such as floods, tsunamis, hurricanes, tornadoes, and wildfires are a major cause of death and injury. These types of disasters result in death and leave many people homeless. Every year millions of Americans face disaster and its terrifying consequences.

High-risk behaviors

such as sexual contact and drug use are common risk factors for HIV and Hep B. People who abuse drugs often share syringes and needles, which increases the risk of acquiring these viruses.

Nurses promote individual and community health by

supporting legislation, acting as positive role models, and working in community-based settings. Because environmental and community values have the greatest influence on health promotion, community and home health nurses are able to assess and recommend safety measures in the home, school, neighborhood, and workplace.

use of diuretics increases

the frequency of voiding and results in the patient having to use toilet facilities more often. Falls often occur with patients who have to get out of bed quickly because of urinary urgency.

If restraints are necessary

the nurse assists family members and patients by explaining their purpose, expected care while the patient is restrained, precautions taken to avoid injury, and that the restraint is temporary and protective.

Patients who have underlying disease states are more susceptible

to fall-related injuries. For example, a patient with a bleeding disorder is more likely to have an intracranial bleed; a patient with osteoporosis has a greater chance for fracture.

type C fire extinguisher

used for electrical equipment.

type B fire extinguisher

used for flammable liquids (e.g., gasoline, grease, paint, and anesthetic gas)

type A fire extinguisher

used for ordinary combustibles (e.g., wood, cloth, paper, and many plastic items)

patients of diverse backgrounds

vulnerability is often intensified for patients of diverse backgrounds. It is a nurse's responsibility to diligently protect all patients, regardless of their socioeconomic status and cultural background. Most untoward events are related to failures of communication. Ensure that you use an approach that recognizes a patient's cultural background so you ask appropriate questions to reveal health behaviors and risks. Also be aware of cultural beliefs about restraints when caring for patients who need restraints.

The probability of an accident occurring declines

when health care providers adhere to evidence-based principles of safety

Teach parents that calling a poison control center for information before attempting home remedies

will save their child's life.

The CMS believes that the Never Events

will strengthen incentives by hospitals to develop safety practices and reduce health care costs in the long term. Health care facilities often conduct a failure mode and effect analysis (FMEA) to identify problems with processes and products before they occur.

The use of restraints is associated

with serious complications resulting from immobilization such as pressure ulcers, pneumonia, constipation, and incontinence. In some cases death has resulted because of restricted breathing and circulation. Patients have been strangled while trying to get out of bed while restrained in a jacket or vest restraint. As a result, many health care facilities have eliminated the use of the jacket (vest) restraint (Capezuti et al., 2008). Loss of self-esteem, humiliation, and agitation are also serious concerns. Legislation emphasizes reducing the use of restraints. Regulatory agencies such as TJC and the CMS enforce standards for the safe use of restraint devices. The optimal goal for all patients is a restraint-free environment.

Safety is enhanced when

you consider patients in light of the whole person and value seeing each care situation through "the patient's eyes" and not just through your own perspective.

On the basis of the results of a fall risk assessment

you implement multiple evidence-based interventions. It is very important to inform a patient and family members about a patient's risks

The mission of the National Quality Forum (NQF) (2011a) is improving the quality of health care in America by:

• Building consensus on national priorities and goals for performance improvement and working in partnership to achieve them; • Endorsing national consensus standards for measuring and publicly reporting on performance; and • Promoting the attainment of national goals through education and outreach programs.

The 2014 Centers for Medicare and Medicaid Services Hospital-Acquired Conditions (Present-on-Admission Indicator)

• Foreign object retained after surgery • Air embolism • Blood incompatibility • Pressure ulcer stages III and IV • Falls and trauma (fracture, dislocation, intracranial injury, crushing injury, burn, electric shock) • Catheter-associated urinary tract infections • Vascular catheter-associated infections • Manifestations of poor glycemic control (diabetic ketoacidosis, nonketotic hyperosmolar coma, hypoglycemic coma, secondary diabetes with ketoacidosis, secondary diabetes with hyperosmolarity) • Surgical site infections following • Mediastinitis following coronary artery bypass graft • Certain orthopedic procedures (spine, neck, shoulder, elbow) • Bariatric surgery for obesity (laparoscopic gastric bypass, gastroenterostomy, laparoscopic gastric restrictive surgery) • Cardiac implantable medical device • Deep-vein thrombosis (DVT)/pulmonary embolism (PE) following certain orthopedic procedures (total knee replacement, hip replacement) • Iatrogenic pneumothorax with venous catheterization

Fire Intervention Guidelines

• Keep the phone number for reporting fires visible on the telephone at all times. • Know the fire drill and evacuation plan of the agency • Know the location of all fire alarms, exits, extinguishers, and oxygen shut-off in your work area. Use the mnemonic RACE to set priorities in case of fire: R—Rescue and remove all patients in immediate danger. A—Activate the alarm. Always do this before attempting to extinguish even a minor fire. C—Confine the fire by closing doors and windows and turning off oxygen and electrical equipment. E—Extinguish the fire with an appropriate extinguisher

Their use must meet one of the following objectives (RESTRAINTS)

• Reduce the risk of patient injury from falls • Prevent interruption of therapy such as traction, IV infusions, nasogastric (NG) tube feeding, or Foley catheterization • Prevent patients who are confused or combative from removing life-support equipment • Reduce the risk of injury to others by the patient

Examples of additional nursing diagnoses for patients with safety risk include the following:

• Risk for Injury • Impaired Home Maintenance • Deficient Knowledge • Risk for Poisoning • Risk for Suffocation • Risk for Trauma

Implications for Patient-Centered Care (restraints)

• When restraints are needed, assess their meaning to the patient and the family. Some cultures may find restraints to be disrespectful. Similarly some survivors of war or persecution or those suffering from post-traumatic stress disorder may view restraints as imprisonment or punishment. • Collaborate with family members in accommodating a patient's cultural perspectives about restraints. Removing the restraints when family members are present shows respect and caring for the patient • Define the protocol of the nursing unit on the use of restraints. Identify potential areas for negotiation with the patient's/family's preferences for using restraints, including having family members stay with the patient.