Unit 11 Safety

Temperature

A person's comfort zone is usually between 18.3° and 23.9° C (65° and 75° F). Exposure to severe cold for prolonged periods causes frostbite and accidental hypothermia. Exposure to extreme heat changes the electrolyte balance of the body and raises the core body temperature, resulting in heatstroke or heat exhaustion.

Health Care Environment

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

Developmental Interventions: Infant, Toddler, and Preschooler/School-Age Child

Educate parents or guardians about reducing risks of injuries to children and ways to promote safety in the home (Table 27-1 pg385). Educate parents about the importance of immunizations and how they protect a child from life-threatening disease.

Near miss

Error of commission or omission that could have harmed a patient, but harm did not occur as a result of chance

Nursing Diagnosis

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

Adult

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.

Nursing History

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. Also review if the patient is taking any medications or undergoing any procedures that pose risks. For example, 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.

Goals and Outcomes

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.

General Preventive Measures part 2

Help parents reduce the risk of accidental poisoning by teaching them to keep hazardous substances such as medications, cleaning fluids, and batteries out of the reach of children. Teach parents that calling a poison control center for information before attempting home remedies will save their child's life. Guidelines for accepted interventions for accidental poisonings are available to teach a parent or guardian (Box 27-11). Older adults are also at risk for poisoning because diminished eyesight may cause an accidental ingestion of a toxic substance/accidental overdose of prescription medications. Be sure that a patient's home medications are kept in their original containers and labeled in large print. Recommend the use of medication organizers that are filled once a week by the patient and/or family caregiver. Patients and family members need to learn how to perform thorough hand hygiene (handwashing or use of a hand rub) and when to use it (i.e., before and after caring for a family member, before food preparation, before preparing a medication for a family member, after using the bathroom, and after contacting any body fluids).

Disasters in the Health Care Environment

Hospitals must be prepared to respond to and care for a sudden influx of patients at the time of a community disaster. Acutely ill patients representing the earliest cases after a covert attack seek care in emergency departments. The early signs of a bioterrorism-related illness often include nonspecific symptoms (e.g., nausea, vomiting, diarrhea, skin rash, fever, confusion) that may persist for several days before the onset of more severe disease. Patients with prodromal illnesses seek outpatient care and are assigned nonspecific diagnoses such as "viral syndrome."

Restraints part 2

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. Informed consent from family members is required before using restraints in long-term care settings. A physician's order is required, 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.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. Proper documentation, including the behaviors that necessitated the application of restraints, the procedure used in restraining, the condition of the body part restrained (e.g., circulation to hand), and the evaluation of the patient response, is essential.

Adolescent

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. 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. 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.

Poison

In the 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. A poison control center is the best resource for patients and parents needing information about the treatment of an accidental poisoning. 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.

Infant, Toddler, and Preschooler

Injuries are the leading cause of death in children over age 1 and cause more death and disabilities than do all diseases combined. 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.

Risk for Falls

Many different fall risk-assessment instruments are available. Most tools include categories on age, fall history, elimination habits, high-risk medications, mobility, and cognition. 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. Often younger patients are not aware of how medications and treatments cause dizziness, orthostatic hypotension, or changes in balance. When patients are unaware of their risks, they are less likely to ask for assistance.

Physical Hazards

Motor vehicle accidents are the leading cause, followed by poisonings and falls. Additional hazards consist of fire and disasters.

Electrical Hazards

Much of the equipment used in health care settings is electrical and must be well maintained. 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.

Impaired Mobility

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.

Disasters

Natural disasters such as floods, tsunamis, hurricanes, tornadoes, and wildfires are a major cause of death and injury.

Procedure-Related Accidents

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. For example, proper preparation and administration of medications, use of patient and medication bar coding, and "smart" intravenous (IV) pumps reduce medication errors. 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. The potential for infection is reduced when surgical asepsis is used for sterile dressing changes or any invasive procedure such as insertion of a urinary catheter. Finally, correct use of safe patient handling techniques and equipment reduces the risk of injuries when moving and lifting patients.

status epilepticus

Prolonged or repeated seizures indicate status epilepticus, a medical emergency that requires intensive monitoring and treatment.

PASS

Pull pin, Aim, Squeeze, Sweep

RACE

Rescue, Activate alarm, Contain, Evacuate

Developmental Interventions: 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. 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.

Acute and Restorative Care

Within hospital and long-term care settings nurses take various measures to maintain patient safety, including fall-prevention strategies, prevention of injuries from use of restraints and side rails, and precautions to prevent fires and exposure to poisoning and electrical hazards. Special precautions are also necessary to prevent injury in patients susceptible to having seizures. Radiation injuries are also a specific safety concern in hospitals. Nurses use standard precautions for all patients to protect themselves from contact with blood and other potentially infectious body fluids. Nurses are responsible for making a patient's bedside safe. Explain and demonstrate to patients how to use the call light or intercom system and always place the call device close to the patient at the conclusion of every nurse-patient interaction. Respond quickly to call lights and bed/chair alarms. Keep the environment free from clutter around the bedside.

Error of execution

YOU did the procedure wrong

Error of commission

YOU did wrong procedure

Error of omission

YOU didn't do procedure

Food and Drug Administration (FDA)

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

pollutant

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

restraint

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

poison

any substance that impairs health or destroys life when ingested, inhaled, or absorbed by the body

Movement away from restraints

bed and chair alarms becoming more common

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).

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)

The mission of the National Quality Forum (NQF)

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.

clonicity

jerking of muscles

To avoid aspiration by bed position.

minimum of 30 degrees

Seizure procedure

privacy, on their side, remove any objects around them, time and circumstance

Immunization

reduces, and in some cases prevents, the transmission of disease from person to person

Safety

the prevention of health care errors and elimination or mitigation of patient injury caused by health care errors

Lack of Safety Awareness

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.

Fall Prevention

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. For example, if a patient has postural hypotension, a nurse chooses a low bed and the practice of dangling the patient for 5 minutes on the side of the bed before ambulating. Or a patient with a history of urinary urgency or incontinence benefits from a bedside commode instead of being expected to walk to the bathroom unassisted. Other interventions include established elimination schedules, placement of a fall pad on the floor along the bed, and use of bed safety alarms or motion detectors. Make sure that patients wear rubber-soled shoes or slippers for walking or transferring. Safety bars near toilets, locks on beds and wheelchairs, and call lights are additional safety features found in health care settings.

Seizures

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. During a seizure the patient often experiences shallow breathing, cyanosis, and loss of bladder and bowel control. A postictal phase follows the seizure, during which the patient has amnesia or confusion and falls into a deep sleep. A person in the community needs to be taken to a medical facility immediately if he or she has repeated seizures; if a single seizure lasts longer than 5 minutes without any sign of slowing down or is unusual in some way; if the person has trouble breathing afterwards or appears to be injured or in pain; or if recovery is different from usual.

Patient's Home Environment

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. 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. Assessment for risk of food infection or poisoning includes assessing a patient's knowledge of food preparation and storage practices. Inform patients who use space heaters of the risk for fires. Are smoke detectors and carbon monoxide detectors up-to-date and functional, and are fire extinguishers present and placed strategically. When patients live in older homes, encourage them to have inspections for the presence of lead in paint, dust, or soil.

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.

General Preventive Measures part 1

Adequate lighting and security measures in and around the home, including the use of night-lights, exterior lighting, and locks on windows and doors, enable patients to reduce the risk of injury from crime. To reduce the risk of injury in the home, remove all obstacles from halls and other heavily traveled areas. Necessary objects such as clocks, glasses, or tissues remain on bedside tables within reach of the patient but out of the reach of children. Take care to ensure that end tables are secure and have stable, straight legs. Place nonessential items in drawers to eliminate clutter. Patients who have problems stumbling or tripping should never have small area rugs in the home. If small area rugs are used, secure them with a nonslip pad or skid-resistant adhesive strips. Accidental home fires typically result from smoking in bed, placing cigarettes in trash cans, grease fires, improper use of candles or space heaters, or electrical fires resulting from faulty wiring or appliances. Teach patients and families how to reduce the risk of electrical injury in the home (Box 27-9). To reduce the risk of fires in the home, instruct patients to quit smoking or smoke outside the home. Have patients with visual deficits install dials with large numbers or symbols on temperature controls.

Falls

Among adults 65 years and older, falls are the leading cause of both fatal and nonfatal injuries. Numerous factors 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). 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 often lead to serious injuries such as fractures or internal bleeding.

Implementation

Among these skills are those involving safe nursing practice during direct care: • Demonstrate effective use of technology and standardized practices that support safety and quality. • Demonstrate effective use of strategies to reduce risk of harm to self or others. • Use appropriate strategies to reduce reliance on memory (e.g., forcing functions, checklists). 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.

aura

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.

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

Humidity

Comfort zone 60-70% Liquefies secretions Improves breathing

Just culture

Do not punish someone for doing something wrong, you want to teach and retrain.

Developmental Interventions: Older Adult part 1

Nursing interventions for older adults reduce patients' risks of falls and other accidents and compensate for the physiological changes of aging (Box 27-8). Educate older adults about safe driving tips (e.g., driving shorter distances or only in daylight, using side and rearview mirrors carefully, and looking behind them toward their "blind spot" before changing lanes). If hearing is a problem, encourage the patient to keep a window rolled down while driving or reduce the volume of the radio. Nursing measures for preventing burns minimize the risk from impaired vision. Reduce pedestrian accidents for older adults and all other age-groups by persuading people to wear reflectors on garments when walking at night; stand on the sidewalk and not in the street when waiting to cross a street; always cross at corners and not in the middle of the block (particularly if the street is a major one); cross with the traffic light and not against it; and look left, right, and left again before entering the street or crosswalk. Also encourage people to assess their walking route for hazards such as unequal or damaged walk ways, unrestrained dogs, and excessive toys; all of these increase the risk for falls.

Oxygen

Oxygen is not flammable, but it is combustible. Smoking is the leading cause of burns, reported fires, deaths, and injuries involving home medical 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. 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. Low concentrations cause nausea, dizziness, headache, and fatigue. Very high concentrations cause death after 1 to 3 minutes of exposure

School-Age Child

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.

Patient-Inherent Accidents

Patient-inherent accidents are 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.

General Preventive Measures part 3

Patients also need to know how to dispose of infected material such as wound dressings and used needles in the home setting. Heavy plastic containers such as hard, colored plastic liquid detergent bottles are excellent for needle disposal. The Environmental Protection Agency (EPA) encourages disposal of used needles by way of community drop-off programs, household hazardous waste facilities, sharps mail-back programs, or home needle destruction devices.

Planning

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.

Pollution

People commonly think of pollution only in terms of air, land, or water pollution; but excessive noise is also a form of pollution that presents health risks. 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. If water becomes contaminated, the public needs to use bottled or boiled water for drinking and cooking.

Lifestyle

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.

Setting Priorities

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).

Environmental Interventions: Basic Needs

Post "No Smoking" and "Oxygen in Use" signs in patient rooms. Do not use oxygen around electrical equipment or flammable products. Store oxygen tanks upright in carts or stands to prevent tipping or falling or place the tanks flat on the floor when not in use. Check tubing for kinks that affect the oxygen flow. Maintain oxygen at the prescribed liter flow and do not change without a health care provider's order. Teach basic techniques for food handling and preparation: • Properly refrigerate, store, and prepare food to decrease the risk of foodborne illness. Store perishable foods in refrigerators to maintain freshness. • Wash hands before and after preparing foods. • Rinse fruits and vegetables thoroughly. • Pay attention to prevent cross-contamination of one food with another during food preparation, especially with poultry. Use separate cutting boards. • Use a separate cutting board for vegetables, meats, and poultry. • Adequately cook foods to kill any residual organisms. Refrigerate leftovers promptly. Bacteria grow quickly at room temperature. • Have family caregivers label the date when leftovers are saved.

Side Rails

Side rails help to increase a patient's mobility and/or stability when repositioning or moving in bed or moving from bed to chair. They are the most commonly used physical restraint. The FDA recommends that all bedrails be used with caution, especially with older adults and people with altered cognition, physical limitations, and certain medical conditions. asically a patient needs to have a route to exit a bed safely and move freely within the bed; in this case side rails are not considered a restraint. For example, raising only the top two side rails of a four rail system gives a patient room to exit a bed safely. Side rails used to prevent a patient, such as one who is sedated, from falling out of bed are not considered a restraint. The use of side rails alone for a patient who is disoriented usually causes more confusion and further injury. Nursing interventions to reduce a patient's confusion first focus on determining and eliminating the cause of the confusion such as a response to a new medication, dehydration, or pain.

Restraint tips

Side rails(can have 3 of 4 up to not be considered restraint)

Fires

Smoking-related fires continue to pose a significant risk because of unauthorized smoking in the bed or bathroom. Institutional fires often result from an electrical fire. The best intervention is to prevent fires. Box 27-13 discusses additional fire-intervention guidelines in health care agencies. Regardless of where a fire occurs, it is important to have an evacuation plan in place. Know where fire extinguishers and gas shut-off valves are located and how to activate a fire alarm. If a patient is on life support, maintain his or her respiratory status manually with a bag-valve-mask device (e.g., Ambu-bag) until he or she is moved away from the fire. Fire extinguishers are categorized as type A, used for ordinary combustibles (e.g., wood, cloth, paper, and many plastic items); type B, used for flammable liquids (e.g., gasoline, grease, paint, and anesthetic gas); and type C, used for electrical equipment.

Risk for Medical Errors

Studies show that overwork and fatigue, particularly when working consecutive 12 hour-shifts, cause a significant decrease in alertness and concentration, leading to errors. For example, 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).

Motor Vehicle Accidents

The American Academy of Pediatrics (AAP, 2011a) recommends that all infants and toddlers ride in the back seat with a rear-facing-only seat and rear-facing convertible 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. The 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. 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. 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.

Risks in the Health Care Agency

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. The National Patient Safety Goals of TJC (2016) are specifically directed to reduce the risk of medical errors (Box 27-2).

Fire

The leading cause of fire-related death is careless smoking, especially when people smoke in bed at home. However, the U.S. Consumer Product Safety Commission estimates that more than 25,000 residential fires every year are associated with the use of space heaters, resulting in more than 300 deaths. The improper use of cooking equipment and appliances, particularly stoves, is a main source for in-home fires and fire injuries. Smoke detectors and carbon monoxide detectors need to be placed strategically throughout a home. Multipurpose fire extinguishers need to be near the kitchen and any workshop areas.

Transmission of Pathogens

The most common means of transmission of pathogens is by the hands. It is important to educate your patients and their family caregivers about the importance of hand hygiene. Hand hygiene is used in all aspects of life, not just in food preparation practices or when caring for a sick family member. You are responsible as a nurse to educate parents about the benefits of immunization.

Patient Outcomes

The patient and family need to participate to find permanent ways to reduce risks to safety. When patient outcomes are not met, ask the following questions: • What factors led to your fall/injury? • Help me understand what makes you feel unsafe in your environment. • What questions do you have about your safety? • Do you need help locating community resources to help make your home safer? • What changes have you recently experienced that you believe contribute to your risk for falling or lack of safety?

Sentinel event

Unexpected occurrence involving death or serious injury

Adverse event

Unintended harm by an act of commission or omission rather than as a result of disease process

Older Adult

The risk of being seriously injured in a fall increases with age. Patients who wander have special safety challenges. 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. Interrupting a wandering patient can increase his or her distress. Older patients are more likely to fall in the bedroom, bathroom, and kitchen in their homes. Environmental factors such as broken stairs, icy sidewalks, inadequate lighting, throw rugs, and exposed electrical cords cause many of the accidents. 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. Main risk factors for developing fear of falling are at least one fall, being female, and being older. Falls can be decreased by group exercise, tai chi, and having cataract surgery. Decreasing hazards in the home that increase falls is also effective. 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).

Falls in the Health Care Agency

The unfamiliar environment, effects of acute illness or surgery, impaired mobility, effects of medications and treatments, and placement of various tubes and catheters place patients of any age at risk of falling. Nurses can implement multifactorial interventions, including assessment and communication about patient risks, staff assignments in close proximity, signage, improved patient hand-offs, nurse toilet and comfort safety rounds, and involving the patient and family.

Restraints part 1

The use of alternatives to restraints is preferred. Current nursing home laws prohibit the unnecessary use of restraints; except in emergencies, nursing homes cannot use restraints without a resident's consent. A physical 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. 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. 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. The optimal goal for all patients is a restraint-free environment. 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.

Restraints part 3

Their use 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 In keeping with current safety trends, electronic devices are alternatives to restraints. Weight and motion sensor mats placed on patients' beds or chairs emit silent or audible alarms when pressure is released off the mat. A less-restrictive restraint is the Posey bed. It is a soft-sided, self-contained enclosed bed that is much less restrictive than chemical or physical restraints.

Adolescent

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.

Bioterrorism

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

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

Nutrition

To protect consumers, commercially processed and packaged foods are subject to Food and Drug Administration (FDA) regulations. 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.

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.

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, 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. • Patient safety continues to be one of the most pressing health care challenges in the nation. • 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 a patient's safety risk and update the nursing care plan appropriately. • Fall risk prevention strategies are implemented on the basis of patients' risk factors, medical history, and condition of patient's environment. • Use physical restraints only as a last resort, when patients' behavior places them or others at risk for injury.

Safety Guidelines For Nursing Skills

• On the basis of your assessment and knowledge of physiological and behavioral factors, anticipate a patient's fall risks when choosing fall prevention strategies. • Involve patients and families in selection of fall prevention strategies. • Always try restraint alternatives before using a restraint. Involve family in your approach. • Protect patients from injury. Follow assessment guidelines while patients are restrained to avoid injury from inappropriate placement. • Protect patients from falling by implementing fall prevention protocols and providing patient and family education about fall prevention.