Nursing 101 - Safety

Sanitation

Refers to measures to promote and establish favorable health conditions, especially those related to the community's water supply.

Preventing the need for restraints.

Restraints are last resort. Provide consistency - keep environment and caregivers consistent to help relieve anxiety. Review medications. Provide relaxation and relieve anxiety - orient patients and families to their surroundings, use therapeutic touch and techniques such as massage, use least invasive and most comfortable method to deliver care, discontinue treatments that cause discomfort or agitation ASAP. Provide frequent assessment and surveillance (family members, friends, or a hired sitter) Find ways to communicate Modify the environment - reduce noise, music therapy, wedge cushions and body props for patients sitting in chairs to help them maintain good posture, use low beds, remove bed rails in some situations, keep doors to unit locked. Anticipate unmet needs - patients often try to get out of bed to get to a toilet. (wandering pt's may be thirsty)

Restraint Free Environments

Restraints never resolve the underlying problem; addressing the reason behind the patients behavior is key to calming the patient.

Etiologies

Risk for Falls r/t poor vision secondary to cataracts. Risk for Falls r/t muscle weakness, joint instability, and poor sense of balance. May include environmental hazards as well as developmental and individual risk factors. Must be specific. Correct: Risk for Falls r/t cluttered home environment and joint stability. Incorrect: Risk for Falls r/t environmental and physical factors.

Firearms

Safety and security is especially important for children or someone I In the home who abuses substances. A risk factor for youth and domestic homicide, as well as unintentional injury.

Keeping equipment safe

Seek advice if unsure how to operate. Properly inspected. Be alert to signs of not functioning. Make sure rooms are not cluttered. Follow agency policies regarding equipment brought from home.

Never Events

Serious Reportable Events. Healthcare acquired complications. 1. can cause serious injury or death to a pt. 2. should never happen in a hospital *Clearly identifiable *Serious *usually are prevented. (Prevent adverse drug events, prevent central line infections, and prevent surgical site infections)

Violence

Situations: A crowded or chaotic environment. Anxiety and anger *Typically begins with anxiety and escalates in stages through verbal aggression and then physical aggression. If you can relieve a patient's anxiety, you may be able to halt the progression to physical violence. Certain emotional and physical conditions. Gang activity.

Suffocation/Asphyxiation

Smothering is Leading cause of death for infants younger than 1. May be caused by drowning, choking on foreign objects, or inhaling gas or smoke. Infants - bed or crib hazards - excess bedding or pillows, or toys hung from long ribbons inside. 1-18 years - Drowning is important cause of accidental death. (children up to 4 especially). Nonfatal - food items (hot dogs, raw vegetables, popcorn, hard candies, nuts, and grapes) are responsible for most nonfatal choking. Fatal - Nonfood items (latex balloons and plastic bags) cause the majority of deaths in young children.

Morse Fall Scale (MFS)

rapid and simple method of assessing a patients likelihood of falling. Six variables with a score tally. 0-24 Low risk 24-44 Medium risk 45+ High Risk

High Reliability

safe operation of an organization without mishap or adverse event. Ranges from amusement parks, and zoos to oil drilling, rigs, air traffic control, and nuclear submarines. -Means having no preventable harm incidents, and causing no harm to patients.

Root Cause Analysis

solves problems by identifying and correcting the underlying causes of events opposed to simply addressing their symptoms. Used for the purpose of redesigning a process or system rather than preventing an individual error. 1. What Happened? 2. Why did this happen? 3. What can be done to prevent it from happening again? JC requires agencies to perform for all unexpected occurrences involving death or serious physical or psychological injury (sentinel events)

Falls

third leading cause of injury related deaths. leading cause for older adults. 4/100 people experience nonfatal but still seek medical advice. More than half occur in the home, 80% involve 65 and older. Triples at 75 and older.

Scald Injuries

(e.g. From hot water, steam or grease). Most common cause of burns in children younger than age 3. Always assess for abuse when there are cigarette burns or injuries (especially on both feet or both hands) in children or vulnerable older adults.

Safety Hazards at Home

* Poisoning - medication, household chemicals, lead, cosmetics. * Carbon monoxide poisoning - treatment- 100% humidified oxygen. * Scalds and burns * Fires * Falls - age >65 at highest risk * Firearms injuries *Suffocation/Asphyxiation- drowning, choking, smoke/gas inhalation, children 0-4yrs at highest risk. * Take home toxins- pathogenic microorganisms, asbestos, lead, mercury, arsenic.

Safety Hazards in the Healthcare Facility

-Falls -Equipment Related Accidents -Fires/Electrical Hazards -Restraints -Side Rails -Mercury Exposure -Biological Hazard -Improper pt. ID. -Medication Errors

Weather Hazards

1000 people die each year in the US. Most likely killer is heat. Number of deaths from lightning, tornadoes, and hurricanes have fallen steadily during the 21st Century, and deaths related to floods have declined because of advances in technology and warning systems.

School-Age Child

6-12 years Involved more with activities outside the home. Injuries are often related to sports, skateboarding, bicycle riding, and playground injuries. Most common are bone and muscle injuries. Accidental deaths - motor vehicle continue to be the leading cause in this age-group Nonfatal injuries - falls are the leading cause of nonfatal injuries.

Chemical Agents

Acid, alkali, or other organic compounds, can also cause localized burns.

Individual Risk Factors

Also influence a person's risk for unintentional injury. These include lifestyle, cognitive awareness, sensoriperceptual status, ability to communicate, mobility status, physical and emotional health, and awareness of safety measures.

Safety Interventions I can delegate

Applying restraints. (not the assessment of the pt's status nor the evaluation of her response) -NAP can remove and reapply restraints to provide skin care and allow supervised movement. -NAP can observe for skin excoriation under or around restraint location and report it to you.

Assessing for Falls

Assess all inpatients for fall risk when they are admitted to the healthcare setting. For patients at risk of falls, repeat the risk assessment every 8 hours and increase the frequency of monitoring. Be sure to identify medications that increase the risk for falling.

Assessing for risk of violence

Assess for factors that increase the risk for aggression.- mental disorders, under the influence, withdrawal, history of violence, Assess for signs of anxiety - agitation and restlessness, pacing, talking loudly or speaking rapidly, gesturing wildly, Verbal aggression (threats, sarcasm, and swearing)

Alarms

Bed or Chair Alarm - sensor pads go under the patients buttocks, will go off with no weight on it. Leg sensors - go on patients thigh. Will sound when leg assumes a near vertical position. Infrared Beam Detector - Attach next to the bed or on the wall. Cord Activated Sensor - attach one end to the patients garment and the other to a monitor. When the cord pulls out then the alarm will go off.

Extinguisher Classifications

Class A - Wood, Paper, rubber, textiles, plastics. Class B - Flammable liquids, gases, oils, solvents, paints, or grease Class C - Live electrical wires or equipment Class D - Combustible metals (potassium, magnesium, titanium) Class E - Kitchen fires involving cooking oils and fats.

Carbon Monoxide Exposure

Colorless, tasteless, odorless toxic gas. Can cause headaches, weakness, nausea, and vomiting. Prolonged exposure leads to seizures, dysrhythmias, unconsciousness, brain damage, and death. Causes 500 unintentional deaths per year. Most occur at home, involves females, children under 17 and adults 18-44. Counts for majority of deaths at the scene of fires and it is also a relatively common method of suicide.

Hazards to Healthcare Workers

Common accidents include back injuries, needlestick injuries, radiation injury, and violence. OSHA requires that employers show employees how to report a workplace injury and prohibits discrimination against employees who make such reports. 52% of nurses report chronic back pain.

Weather Hazard Safety Measures

Develop a disaster plan, Identify safe place to take shelter, know the country/parish in which you live or visit, keep a highway map nearby, have a weather radio receiver unit with a warning alarm, check the weather forecast before leaving for extended periods outdoors, if severe weather threatens, check on people.

Documentation of alarms

Document initial sensor placement, type, and location. Follow agency policy for documenting the use of bed exit monitor (usually minimum is every 8 hours.) Document on the fall risk assessment sheet, restraint flow sheet, and nursing notes according to agency policy.

Institute of Medicine

Err is Human: Building a Safer Health System: Stated that it is simply not acceptable for patients to be harmed by the same healthcare system that is supposed to offer healing and comfort. Five critical principles to ensure safe healthcare systems: Provide leadership, recognize human limits in process design, promote effective team functioning, anticipate the unexpected, and create a learning environment.

Planning Interventions/Implementation

Examples: Aspiration Precautions, Dementia Management, Emergency Care, Environmental Management: Safety, Fall Prevention, First Aid, Home Maintenance Assistance, Sports-Injury Prevention: Youth, Surveillance: Safety.

Planning Outcomes/Evaluation

Examples: Aspiration Prevention, Community Disaster Response, Fall Prevention Behavior, Parenting: Infant/Toddler Physical Safety, Personal Safety Behavior, Physical Injury Severity, Respiration Status: Airway Patency, Safe Home Environment, Thermoregulation. Individual goals/outcomes statements: The child is free of injury. Client will experience no physical injury due to environmental hazards. Family members will describe their planned escape routes in case of fire.

Radiation Injury

Follow the principles of time, distance, and shielding when caring for a patient who is being treated with an internal radioactive implant. Time - organize nursing care to limit the amount of time with the pt. Distance - Perform near the patient only the nursing care that is absolutely necessary. Shielding - Wear protective shielding (lead apron). If you deliver care that regularly exposes you to radiation, wear a film badge to indicate any radiation exposure

Needlestick Injury

OSHA require employers to maintain a log of sharps injuries and to purchase needless systems and safer medical and needle devices. 1000 sharps injuries per day in US hospitals. Risk increases: Work in stressful environments. Work varying or long shifts. Low skill level based on education or experience. Lack of PPE, recapping needles, and working in an area that requires higher than average use of needles.

American Nurse's Association

Health System Reform - recommends six major public changed that can raise the quality of healthcare. Quality Aim 1 is safe healthcare.

Healthcare Culture

Healthcare professionals, including nurses have been taught to practice with autonomy. Many healthcare organizations are working to address disrespectful behavior, staff reluctance to speak up about risks and errors, and blatant disregard of expressed concerns.

Assessing for Home Safety

Home safety Checklist. The Safety assessment scale - objective way to evaluate the dangers incurred by people with memory and cognitive deficits who live alone. Makes sure they are able to take medications, and perform ADL's.

Analysis/Nursing Diagnosis

Hyperthermia, Hypothermia, Risk of Aspiration, Risk for contamination, risk for falls, risk for injury, risk for poisoning, risk for suffocation, risk for physical trauma. Use Risk of Injury only when the risk cannot be described by one of the more specific nursing diagnoses.

Safety Hazards In the Healthcare Facility

IOM estimated 98k people die from medical injuries each year. The number of deaths has grown to 400k as a result of medical errors (3rd leading cause of death in the US) Organization Factors: Poor Design Maintenance failures, unworkable procedures, shortfalls in training, less than adequate tools and equipment, inadequate staffing, disruptive behavior or intimidation in the workplace, culture of disrespect among healthcare professionals. Hospitals are smoke free. Fires are related to anesthesia or malfunctioning electrical equipment.

Timed up and Go Test

If the pt. is seeking care because of a fall or if you observe any difficulty with ambulation, refer him to a practitioner with advanced skills. Pt. is asked to get up and walk 8 feet in 8.5 seconds or less. PCP's should annually perform for fall risk assessment for all patients over 65.

Soil

Improper waste disposal and excessive use of pesticides can contaminate. Animals, radioactive and medical waste pose special problems. Household products contain corrosive or toxic ingredients the contaminate the environment when disposed of improperly.

Preventing violence

Intervene to relieve anxiety. Treat underlying medical conditions. Administer sedatives like diazepam or lorazepam. Use calm, reassuring approach. Avoid aggressive body language. Don't defend when pt is verbally aggressive. Don't wear stethoscope around your neck. Remove objects in room that can be a weapon. Keep room door open. Remain at least arm's length Don't turn your back to the pt. Do not touch without permission. As a last resort, use restraints if ordered and necessary.

Fires

Major cause of death and injury. Older adults and children under 5 have the greatest risk of death. Cooking fires are the number one cause of home fires and home injuries. Most fatal occur while people are asleep and most deaths occur from smoke inhalation. Common causes: Smoking, heating equipment, Home oxygen administration equipment, children playing with matches, improper use of candles, and faulty wiring.

Safety Hazards in the Home.

Most fatal accidents occur. Leading causes of death are poisonings, falls, fires, burns, and choking. For children, maternal mental health problems, and have older siblings are associated with less safe homes.

Safety Hazards in the Community

Motor vehicle accidents, pathogens, pollution, and weather hazards. Major contributor to illness, disability, and death worldwide.

Community Intervention - Teaching for Safety Self-Care

Motor vehicle safety. Food safety. Fighting Vector-Borne Pathogens. Mosquitos - Remove sources of stagnant water, kill or repel, avoid, consult the experts. Ticks - wear repellent, wear light colored clothing, after walking inspect your body. Rodents and other animals - cover food, do not leave unwashed dishes, keep garbage in closed containers, repair holes, use commercial traps. Reduce Pollution - air pollution, noise pollution, hazardous waste, solid waste (the 4 r's - reduce, reuse, recycle, respond)

Culture of Safety

Nurses practice in an environment where all staff work together to create a safe unit, disclose errors without fear, and address any safety concerns. Team empowerment, Communication, Transparency, Accountability.

Alarm Fatigue

Occurs when nurses become desensitized to patient care alarms and then miss or delay response to an alarm

Intrinsic Factors the Increase the risk of falls

Older than 75. History of falling. Bowel or bladder incontinence, cognitive impairment, mood changes, dizziness, functional impairment, medications, comorbidities (dementia, hip fracture, Parkinson's) Increase risk for more severe injury in case of a fall. (Coumadin, Plavix or Aspirin) and osteoporosis.

Adolescent

Peak physical, sensory, and psychomotor abilities give teenagers a feeling of strength and confidence, yet they lack the wisdom and judgement of adults. Feelings of being indestructible makes them more likely to participate in risk taking behavior. Accidental Death - motor vehicle accidents are the leading cause, followed by homicide. Both are frequently associated with alcohol and drug use. Accidental Injuries - Sports and Recreational injuries, including diving and drowning incidents, are also common, especially when drinking and drug use are involved.

Older Adult

Physiological changes occur. These changes increase their risk of falls, burns, car accidents, and other injury. Accidental Deaths - falls are the most common cause of accidental death for ages 65 and older.

Home Care Safety Interventions

Prevent poisoning in the home: call 911 right away. Or no symptoms call poison control center. Never induce vomiting with ingested being acidic or caustic. Prevent carbon monoxide poisoning - CO detector, ensure gas or wood burning appliances are vented outside, repair rust holes or defects in vehicles, do not use kerosene heaters, Never operate gasoline powered engines indoors, never burn charcoal inside the home. Prevent home fires - Have a warning system, escape plan (practice twice a year), Have a preventive state of mind (always unplug Christmas tree lights, Never leave candles burning unattended, Do not smoke in bed), promote electrical safety, know what to do if a fire occurs. Prevent scalds and burns. Prevent firearm injuries - teach children, and keep them away. Prevent suffocation. Choking rescue - teach universal sign of choking. Prevent drowning. Prevent take-home toxins

Intervention: Promoting Safety in the Healthcare Facility

Preventing Falls, Reducing electrical hazards, Responding to Fires (RACE)

Reducing alarm fatigue

Provide proper skin preparation for ECG electrodes. Change ECG at least daily. Set alarm parameters and levels on ECG monitors for individual. Collaborate with team to customize delay and threshold setting on oxygen saturation via pulse oximetry monitors. Provide education Establish teams to address issues such as development of policies and procedures related to alarms. Monitor only those patients with the clinical indications for monitoring.

Poisoning

Quadrupled in the past 20 yrs. Increase is mainly adults. In many cases the person does not die but becomes ill or suffers other side effects. Exposure amounts to 7k ED visits per day. Young children - mostly from improper storage of household chemicals, medicines, vitamins and cosmetics. Lead pain can still be found in older homes. Poor urban and immigrant populations are at high risk for lead exposure. Older children and adolescent - may attempt suicide by overdosing or accidently when experimenting. Adults - result of illegal drug use or misuse or abuse of prescription drugs, especially narcotics, tranquillizers and antidepressants.] Treatment Choice - for most professionally administration of activated charcoal orally or via gastric tube. However not effective for ethanol, alkali, iron, boric acid, lithium, methanol, or cyanide. Other options may include gastric lavage, dialysis, administration of antidotes, and forced diuresis.

Water Borne Pathogens

Some people who live in standardized housing may not have safe drinking water, hot water for washing, or adequate methods of waste disposal. People in rural areas often depend on private wells, which may not be maintained and tested for pathogens such as Giardia lambia, Cryptosporidium, and E. Coli.

Noise

Substantial exposure is associated with adverse health effects, hearing loss, stress, elevated blood pressure, and loss of sleep.

Get up and Go test

Use if there is a history of falls. If pt or caregiver reports a single fall or risk factors conduct the test. Have the pt do the following: Move from sitting position and stand without using his arms to help him rise and stand Walk several paces, turn, and return to chair. Sit back in the chair without using arms for support.

Preventing needlestick injury

Use needless systems. Provide adequate lighting and space place sharps container near the work area obtain assistance if risk of pt. may not be cooperative Inform and explain to pt. Be sure you can see sharps container at all times. Be aware of persons around you do not hand passed exposed sharps to on person to another using safety needle, observe for audio or visual cues that the feature has engaged. do not shear or break contaminated needles avoid recapping, bending, or removing contaminated needs and other sharps unless there is feasible alternative. when you must recap a sterile needle, use a mechanical recapping device or modified scoop technique. Never carry syringes in uniform pocket.

Extrinsic (environmental) factors for increase of falling

Use of assistive device, equipment in room, wet or uneven floors, physical restraints, poorly fitting footwear, poor lighting, lack of grab rails and bars in bathroom, furniture and adaptive aids that are in disrepair or unstable, clothing that may cause tripping, check the alarm and monitoring device to ensure that it is working properly.

Adult

Workplace injury may be significant concern. Other injuries are related to lifestyle, stress, carelessness, abuse, and decline in strength, and stamina. Accidental Death - Unintentional poisoning causes more deaths than do motor vehicle accidents Accidental Injuries - for many, work and family responsibilities leave little time for regular physical activity, increasing the risk of musculoskeletal injury in the so-called weekend athlete.

Quality and Safety Education for Nurses (QSEN)

a task force to improve nursing education, identified and described six competencies that all nursing students should have by graduation. Safety is one of those competencies.

Safety

basic human need, second only to survival needs such as oxygen, nutrition, and fluids. Accidents or unintentional injuries are the 4th leading cause of deaths in the US. Estimated 130,000 people die each year as a result of accidents. Poisoning is listed as number one cause of unintentional death, followed by motor vehicle accidents, firearms, drowning and fires.

Joint Commission

accrediting body for healthcare facilities, each year publishes National Patient Safety Goals. Ex. 2016 goals include improving the accuracy or patient identification, improving the safety of medication use, reducing the risk of healthcare associated infections, and preventing mistakes in surgery.

Pollution

any harmful chemical or waste material discharged into the air, water or soil. Air pollution - indoor and outdoor. Outdoor - motor vehicle emissions are major cause. Others include asbestos, toluene; metals such as mercury and lead compounds, and emissions from sources such as factories, and power plants. Indoor - radon, carbon monoxide, allergens from dust mites, cockroaches, mold, rodents and pets.

Sunburn

can cause first or second degree burns

Contact Burns

can occur from contact from metal surfaces and vinyl seats when cars are parked in the sun. The risk in all age groups is greater in the presence of heating devices, such as kerosene heaters, wood-burning stoves, and home sauna heating elements.

Infant/Toddler

can't recognize the danger, kids love to touch, eat, explore, At high risk for-drowning, falls, choking, poison. Drowning is the leading cause of death followed by motor vehicle accidents. Falls, Choking, SIDS and ingesting poisons are the other critical safety concerns.

Warming food or formula in microwave

cause the food to become hotter than intended, leading to burns in infants and young children.

Mercury

heavy, odorless, silver white liquid metal. Toxic in both acute and chronic exposure. Can be inhaled, ingested, or absorbed in skin. Accumulates in muscle tissue and cause renal and neurological disorder especially in fetuses and neonates. Products: Thermometer, thermostats, batteries, fluorescent light bulbs, blood pressure devices, and electrical equipment and switches.

Restraints

device or method used for the purpose of restricting a patients freedom of movement or access to his body, with or without his permission. 1. Mechanical device, material, or equipment, such as cloth vests or side rails. 2. Chemical restraint (sedatives or medications) Devices such as casts and traction are not considered restraints. Physical holding of a pt. is not always considered restraint. Restraints are classified according to their reason for their use: med-surg restraints or behavior restraints. Medicare has specific guidelines for each. Older adults with impaired cognition - consume time, do not reduce falls, Safety hazard and increase likelihood of injury. Must be medically prescribed. Must try all other less restrictive interventions. Must have physician order - reevaluate in 24 hours. A safety check by RN must be done within 30 minutes after. Release and offer fluids every 2 hours. Assess every 30 minutes.

Medicare

federal agency that has identified "never events" or hospital acquired conditions. costly errors that cause serious injury or death, and that are mostly preventable (falls, injuries from restraints). They will no longer pay institutions for care required to treat the effects of such errors.

Equipment Related Accidents

happens with equipment malfunction or improper use.

Take Home Toxins

hazardous substances transported from the workplace to the home Pathogenic microorganisms, asbestos, lead, mercury, arsenic, pesticides, caustic farm products, and other agents cause significant morbidity and mortality in workers' homes. Transported by: Direct skin to skin or direct contact with contaminated clothing. Arthropod vectors, such as ticks. Dust particles that are inhaled (anthrax spores, arsenic in mine, and smelter dust)

Cleaning Mercury

if not properly cleaned, can stay in cracks and crevices for long periods of time. Large spills usually must be cleaned by a pollution control agency. Do not touch droplets. If you are not trained, do not attempt to clean. Dispose of clothing or other items that have been contaminated. Ventilate the area. Complete occurrence report. If in healthcare - spill kits. Home - wear rubber gloves, and eye protection. Use paper towels, and plastic bag for disposal. Hard surfaces use cardboard to scrape up beads, and pour them into jar with a lid. Do not use broom or vacuum cleaner. Do not wash and reuse contaminated materials.

Food Borne Pathogens

illness caused by ingesting bacteria and other microorganisms or their toxins in food. Improper food storage and preparation. Raw foods. Poisonous chemicals in the environment.

Motor Vehicle Accidents

leading cause of accidental death. Teens and young adults account for 38% of ER visits. Older adults are at higher risk. Everyday an average of 500 people over age 65 are injured. Major Contributors: Failure to use seat belts, air bag deployment, driver distraction, speed, alcohol, and nonuse of motorcycle helmets.

Preschooler (3-5 years)

learn to initiate tasks and carry out plans, or they feel guilty about efforts to be independent. Play outside more (playgrounds, Pools.) Accidental Deaths - Motor vehicle injuries are a major cause, along with drowning, fires and poisoning. Nonfatal injuries - falls are the primary cause of nonfatal injuries. Adult supervision is essential.

Quality Nursing Care

nurses are the healthcare professionals who spend the greatest amount of time with patients, research documents what physicians, patients, and nurses themselves have long known. Effects patient health and outcomes and sometimes can be a matter of life and death. Greater number of pt. deaths are associated with fewer nurses to provide care. Less nursing time provided to patients is associated with higher rates of infection, gastrointestinal bleeding, pneumonia, cardiac arrest, and death from these and other causes.

Water Contamination

occurs when inadequately treated or inappropriate quantities of human, industrial, or agricultural wastes are released into the water systems. If sever enough the water may become unsafe for human consumption.

Vector Borne Pathogens

organisms that transmit pathogenic bacteria, viruses, and protozoa from one host to another. Mosquitos (west nile virus and malaria)(canine heartworm, equine encephalitis), Roaches, Fleas, sand flies, lice and ticks. (Allergic sensitivity to cockroaches is a predictive factor for asthma severity). Structural defects in a building permit entry of birds, rodents, and other small animals. (Rabies can be spread through bite of a rabid animal. Some fungal diseases can spread via the inhalation of bird droppings. Mouse proteins have been implicated in the occurrence of asthma.)