NUR 101 Patient Safety (Potter)

Lead

-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 -Falls can be decreased by multiple-component group exercise, Tai Chi, having a physician or pharmacist review all medications, having an eye examination annually, and decreasing hazards in the home that increase falls

Health Care Environment

Does the placement of equipment (e.g., drainage bags, IV pumps) or furniture pose barriers when the patient attempts to ambulate? Does positioning of the patient's bed allow him or her to easily reach items on a bedside table or stand? Does the patient need assistance with ambulation? Are there multiple tubes or IV lines? Is the call bell within reach?

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 using an appropriate extinguisher

Factors Influencing Patient Safety

developmental level; mobility, sensory, and cognitive status; lifestyle choices; and knowledge of common safety precautions, also special risks to safety that are found in health care settings

Medical errors

happen when something that was planned as part of medical care doesn't work out or when the wrong plan was used

seizure

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). -Before a convulsive episode a few patients report an aura, which serves as a warning or sense that a seizure is about to occur. An aura is often a bright light, smell, or taste

Individual Risk Factors

lifestyle, impaired mobility, sensory or communication impairment (delirium, dementia, and depression), and the lack of safety awareness

do interactive review

p 395 Potter

Posey bed

soft-sided, self-contained enclosed bed that is much less restrictive than chemical or physical restraints

delegated to nursing assistive personnel (NAP) restraits

the nurse must first assess the patient's behavior, level of orientation, need for restraints, and appropriate type to use. The assessment while a restraint is in place cannot be delegated to NAP. The nurse directs NAP by: •Reviewing correct placement of the restraint. •Reviewing when and how to change patient's position. •Instructing NAP to notify nurse if there is a change in skin integrity, circulation in extremities, or patient's breathing. •Instructing to provide range of motion (ROM), nutrition and hydration, skin care, toileting, and opportunities for socialization.

Safety

-*freedom from psychological and physical injury* -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 the patient's sense of well-being

Nursing Assessment Questions

*Activity and Exercise* • Do you use any assistive devices such as a wheelchair, walker, or cane to help you move or get around? Did someone show you how to use them safely? • Do you have any difficulty bathing? Dressing? Eating? Using the bathroom? Transferring out of the bed or chair? • What type of exercise or physical activity do you get? How often? • How do you handle meal preparation (e.g., use stove and appliances safely)? • Do you do your own laundry? How do you do this, and where are these appliances located? • Do you drive an automobile? When do you normally drive? How far? • How often do you wear a safety belt when in the car? • Have you recently been involved in a motor vehicle accident? *Medication History* • Which medications (prescription, over-the-counter, herbal) do you take? • Has your doctor or pharmacist reviewed your medicines with you? • Do any medications make your dizzy or light-headed? *History of Falls* • Have you ever fallen or tripped over anything in your home? • Have you ever suffered an injury from a fall? What was it and how did it happen? • Did you have any symptoms right before you fell? What were they? • Which activity were you performing before the fall? *Home Maintenance and Safety* • Who does your simple home maintenance or minor home repairs? • Who shovels your snow? Tends to your lawn? • Do you feel safe in your home? Which things in your environment make you feel unsafe? • Do you have someone to call in case of an emergency? • How do you feel about modifying your home to make it safer? Do you need help finding resources to help you do this?

National Patient Safety Goals for Hospitals

*Identify patients correctly* •Use at least two patient identifiers. •Eliminate transfusion errors. * Improve staff communication* •Report important test results in a timely manner *Use medicines safely* •Label medications. •Reduce harm to patients who take anticoagulation therapy. *Reduce the risk of health care-associated infections* • Meet hand hygiene guidelines. • Prevent multidrug-resistant organism infections. • Prevent central line-associated bloodstream infections. • Use safe practices to treat the part of the body where surgery was performed. *Check patient medicines* •Identify current medicines and make sure that it is okay for patients to take any new medicines with current medicines. •Give a list of patient's medicines to the next provider before discharge. •Give a list of patient's medicines to patient and family before discharge; explain the list. *Identify patient safety risks* •Identify individuals at risk for suicide

NQF List of Serious Reportable Events

*Surgical Events* 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 *Product or Device Events* 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 or 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 *Patient-Protection Events* 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 *Care-Management Events* 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 *Environmental Events* 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 *Criminal Events* 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

Transmission of Pathogens

*pathogen* is any microorganism capable of producing an illness -most effective methods for limiting the transmission of pathogens is the medically aseptic practice of hand hygiene -*Immunization* also reduces, and in some cases prevents, the transmission of disease from person to person

Falls

- adults 64 years and older, falls are the leading cause of unintentional death -factors increase the risk of falls, including a history of falling, being age 65 or over, reduced vision, orthostatic hypotension, gait and balance problems, urinary incontinence, use of walking aids, and the effects of various medications (e.g., anticonvulsants, hypnotics, sedatives, certain analgesics)

Disasters

- floods, tsunamis, hurricanes, tornadoes, and wildfires -Bioterrorism -use of biological agents to create fear and threat, is the most likely form of a terrorist attack to occur -health officials are most concerned with biological agents such as anthrax, smallpox, pneumonic plague, botulism, tularemia, and viral hemorrhagic fevers

Nursing History

- includes data about a patient's level of wellness to determine if any underlying conditions exist that pose threats to safety -ex) use of diuretics increases the frequency of voiding and results in the patient having to use toilet facilities more often

Interventions to Promote Safety for Children and Adolescents

-Have infants sleep on their back or side. Teach parents the mnemonic "back to sleep." -Do not fill cribs with pillows, large stuffed toys, or comforters. Use snug-fitting sheets. -Do not attach pacifiers to string or ribbon and place around a child's neck. -Follow all instructions for preparing and storing formula. -Use large, soft toys without small parts such as buttons. -Do not leave the mesh sides of playpens lowered; spaces between crib slats need to be less than inches (6 cm) apart. -Never leave crib sides down or babies unattended on changing tables or in infant seats, swings, strollers, or high chairs. -Discontinue using accessories such as infant seats and swings when the child becomes too active or physically too big and/or according to the manufacturer's directions. -Never leave a child alone in the bathroom, tub, or near any water source (e.g., pool). -Baby-proof the home; remove small or sharp objects and toxic or poisonous substances, including plants; install safety locks on floor-level cabinets. -Remove plastic bags from the cleaners or grocery store from the home. -Cover electrical outlets. -Place window guards on all windows. -Install keyless locks (e.g., deadbolts) on doors above a child's reach, even when they are standing on a chair. -Put children weighing less than 80 pounds or under 8 years of age in an age/weight-appropriate car seat that has been installed according to manufacturer's instructions (see Fig. 27-1). This includes car seats and booster seats. In cars with a passenger air bag, children under 12 need to be in the back seat. All passengers need to wear seat belts. -Caregivers need to learn cardiopulmonary resuscitation (CPR) and the Heimlich maneuver. (p. 379 for rationale)

National Quality Forum (NQF) 2011

-National Voluntary Consensus Standards for Public Reporting of Patient Safety Events -report provides a framework for publicly reporting patient safety information—including events, indicators, and measures—about health care organizations to consumers

Restaints

-Patients who are confused, disoriented, or repeatedly fall or try to remove medical devices (e.g., oxygen equipment, IV lines, or dressings) often require the temporary use of restraints to keep them safe -any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely -Use of restraints must meet one of the following objectives: •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

Preschoolers

-Teach children to swim at an early age but always provide supervision near water. -Teach children how to cross streets and walk in parking lots. Instruct them to never run out after a ball or toy. -Teach children not to talk to, go with, or accept any item from a stranger. -Teach children basic physical safety rules such as proper use of safety scissors, never running with an object in their mouth or hand, and never attempting to use the stove or oven unassisted. -Teach children not to eat items found in the street or grass. -Remove doors from unused refrigerators and freezers. Instruct children not to play or hide in a car trunk or unused appliances.

Physical Hazards

-Unintentional injuries are the fifth leading cause of death for Americans of all ages (National Center for Injury Prevention, 2010a) -Motor vehicle accidents are the leading cause. followed by poisonings and falls

Pollution

-a harmful chemical or waste material discharged into the water, soil, or air (excessive noise) -

Fall Assessment Tool

-age -fall history - elimination -medications -patient care equipment -mobility -cognition ______total: >13 high risk ______total: 6-13 moderate risk

Environmental Safety

-all of the many physical and psychosocial factors that influence or affect the life and survival of that patient -meeting basic needs, reducing physical hazards and the transmission of pathogens, and controlling pollution -vulnerable groups: infants, children, older adults, the ill, the physically and mentally disabled, the illiterate, and the poor

Poison

-any substance that impairs health or destroys life when ingested, inhaled, or absorbed by the body -poison control center is the best resource for patients and parents needing information about the treatment of an accidental poisoning

Fire

-leading cause of fire-related death is careless smoking, especially when people smoke in bed at home -improper use of cooking equipment and appliances, particularly stoves, is the main source for in-home fires and fire injuries

Institute of Medicine's report To Err Is Human: Building a Safer Health System (2000)

-pivotal publication that brought patient safety to the forefront of health care in the United States -44,000 to 98,000 people die each year as a result of preventable medical errors

Nursing Diagnosis

-risk for injury related to altered mobility or sensory alteration (e.g., visual) • Risk for falls • Impaired home maintenance • Risk for injury • Deficient knowledge • Risk for poisoning • Risk for suffocation • Risk for trauma ex) impaired physical mobility related to left-sided paralysis, the goal is the patient "remains free of injury by discharge" •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.

Motor Vehicle Accidents

-seat belts, air bags, and laminated windshields (remain in one piece when impacted) - all infants and toddlers ride in the back seat with a rear-facing car safety seat until they are 2 years of age or they reach the highest weight or height allowed by the manufacturer of the car safety seat -back seat of a car is the safest part of the vehicle in the event of a crash and prevents injury from deployment of passenger and side air bags -Per mile traveled, fatal crash rates increase starting at age 75 and increase markedly after age 80

Food and Drug Administration (FDA)

-set regulations to protect consumers, commercially processed and packaged foods -manufacture, processing, and distribution of foods, drugs, and cosmetics to protect consumers against the sale of impure or dangerous substances

Intervening in Accidental Poisoning

1 Assess for signs or symptoms of ingestion of harmful substance such as nausea, vomiting, foaming at the mouth, drooling, difficulty breathing, sweating, and lethargy. 2 Terminate exposure to the poison by having the person empty his or her mouth of pills, plant parts, or other material. 3 If poisoning is caused by skin or eye contact, irrigate the skin or eye with copious amounts of cool tap water for 15 to 20 minutes. In the case of an inhalation exposure, safely remove the victim from the potentially dangerous environment. 4 Identify the type and amount of substance ingested to help determine the correct type and amount of antidote needed. 5 If the victim is conscious and alert, call the local poison control center or the national toll-free poison control center number (1-800-222-1222) before attempting any intervention. Poison control centers have information needed to treat poisoned patients or offer referral to treat. The administration of ipecac syrup is no longer recommended for routine home treatment of poisoning. 6 If the victim has collapsed or stopped breathing, call 911 for emergency transportation to the hospital. Initiate CPR if indicated until emergency personnel arrive. Ambulance personnel can provide emergency measures if needed. In addition, a parent or guardian is sometimes too upset to drive safely. 7 Position the victim with head turned to side to reduce risk for aspiration. 8 Never induce vomiting if the victim has ingested the following poisonous substances: lye, household cleaners, hair care products, grease or petroleum products, furniture polish, paint thinner, or kerosene. 9 Never induce vomiting in an unconscious or convulsing victim because vomiting increases risk for aspiration.

Basic Needs

Physiological needs, including the need for sufficient oxygen, nutrition, and optimum temperature (influence safety)

delegated to nursing assistive personnel (NAP) seizures

The skill of seizure precautions cannot be delegated to nursing assistive personnel (NAP). However, the skills for making the environment safe can be delegated. The nurse directs NAP by: • Explaining patient's prior seizure history and factors that typically trigger a seizure. • Emphasizing not to try to restrain patient or place anything in patient's mouth.

Teaching Strategies (Fire Extinguisher in the Home)

• Discuss how to choose a correct location for an extinguisher. It is recommended that one be placed on each level of the home, near an exit, in clear view, away from stoves and heating appliances, and above the reach of small children. Keep a fire extinguisher in the kitchen, near the furnace, and in the garage. Make sure that patients read instructions after purchasing the extinguisher and keep them for periodic review. • Describe the steps to take before using the extinguisher. Attempt to fight the fire only when all occupants have left the home, the fire department has been called, the fire is confined to a small area, there is an exit route readily available, the extinguisher is the right type for the fire (see discussion in text for a description of the types of extinguishers), and the patient knows how to use it. • Instruct the patient to memorize the mnemonic PASS: Pull the pin to unlock handle, Aim low at the base of the fire, Squeeze the handles, and Sweep the unit from side to side

Teaching Strategies (Electrical Hazards)

• Discuss importance of checking for grounding of electrical appliances and other equipment. • Provide examples of common hazards: frayed cords, damaged equipment, and overloaded outlets. • Discuss guidelines to prevent electrical shocks:•Use extension cords only when necessary and use electrical tape to secure the cord to the floor, preferably against baseboards. •Do not run wires under carpeting. •Grasp the plug, not the cord, when unplugging items. •Keep electrical items away from water. •Do not operate unfamiliar equipment. •Disconnect items before cleaning. • Have patient list electrical hazards existing in the home. • Review steps the patient will take to eliminate these hazards. • Check the home after the patient has had an opportunity to eliminate hazards.

2009 Centers for Medicare and Medicaid Services Hospital-Acquired Conditions

• 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) • Deep vein thrombosis and pulmonary embolism following certain orthopedic procedures (total knee replacement, hip replacement)

Key Points

• In the community a safe environment means that basic needs are achievable, physical hazards are reduced, transmission of pathogens and parasites is reduced, pollution is controlled, and sanitation is maintained. • A safe health care environment is one that reduces the risk of injury, including minimizing falls, patient-inherent accidents, procedure-inherent accidents, and equipment-related accidents. • Reduction of physical hazards in the environment includes providing adequate lighting, decreasing clutter, and securing the home. • Reduce the transmission of pathogens through medical and surgical asepsis, immunization, adequate food sanitation, insect and rodent control, and appropriate disposal of human waste. • Every developmental age involves specific safety risks. • Children younger than 5 years of age are at greatest risk for home accidents that result in severe injury and death. • The school-age child is at risk for injury at home, at school, and while traveling to and from school. • Adolescents are at risk for injury from automobile accidents, suicide, and substance abuse. • Threats to an adult's safety are frequently associated with lifestyle habits. • Risks for injury for older patients are directly related to the physiological changes of the aging process. • Nursing interventions for promoting safety are individualized for patients' developmental stage, lifestyle, and environment. • Continually evaluate the patient's safety risk and update the nursing care plan appropriately. • Use physical restraints only as a last resort, when patients' behavior places them or others at risk for injury.

Older Adults

• Older adults experience visual and hearing alterations. Encourage annual vision and hearing examinations and frequent cleaning of glasses and hearing aids as a means of preventing falls and burns. • Some older adults have slowed reaction time. Teach patients safety tips for avoiding automobile accidents. Sometimes driving needs to be restricted to daylight hours or temporarily or permanently suspended. • Range of motion, flexibility, and strength decrease. Encourage supervised exercise classes for older adults and teach them to seek assistance with household tasks as needed. Safety features such as grab bars in the bathroom are often necessary. • Reflexes are slowed, and the ability to respond to multiple stimuli is reduced. Provide adequate, meaningful stimuli but prevent sensory overload. • Nocturia and incontinence are more frequent in older adults. Institute a regular toileting schedule for the patient. A recommended frequency is every 3 hours. Give diuretics in the morning. Provide assistance, along with adequate lighting, to patients who need to go to the bathroom at night. • Memory is sometimes impaired. Patients need to use medication organizers, which can be purchased at any drugstore at a very reasonable cost. Fill these dispensers once a week with the proper medications to be taken at a specific time during the day. • The family plays a significant role in the care of older adults. There are 65.7 million unpaid caregivers for adults, who are mostly family members (National Alliance for Caregiving, 2011). These family caregivers spend an average of 19 hours per week providing care (National Alliance for Caregiving, 2009). Encourage the family to allow the older adult to remain as independent as possible and provide help only for those things that are especially stressful or depleted. • The high prevalence of chronic conditions in older adults results in the use of a high number of prescription and over-the-counter medications. Coupled with age-related changes in pharmacokinetics, there is a greater risk of serious adverse effects. Medications typically prescribed for older adults include anticholinergics, diuretics, anxiolytic and hypnotic agents, antidepressants, antihypertensives, vasodilators, analgesics, and laxatives, all of which pose risks or interact to increase the risk for falls. Review the patient's drug profile to ensure that these drugs are used cautiously and assess the patient regularly for any adverse effects that increase fall risk.

Resources Related to Safety and Safety Initiatives

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

Restraints

• When restraints are needed, assess their meaning to the patient and the family. For example, some Asian families view the restraining of older adults as disrespectful. Similarly some survivors of war or persecution 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 such as using a jacket versus arm restraints.

Features that alert nurses to the possibility of a bioterrorism-related outbreak

•Disease (or strain) not endemic •Unusual antibiotic resistance patterns •Atypical clinical presentation •Case distribution geographically (from same location) and/or temporally inconsistent •Other inconsistent elements (e.g., number of cases, mortality and morbidity rates, deviations from disease occurrence baseline)