Chapter 4: Patient Safety and Quality Improvement

Practice Standards

-Agency for Healthcare Research and Quality (AHRQ), 2013: Preventing falls in hospitals—Evidence-based interventions for fall prevention -American Epilepsy Society (Glauser et al.), 2016: Evidence-based guideline: treatment of convulsive status epilepticus in children and adults—Treatment of status epilepticus -National Institute for Health and Care Excellence (NICE), 2014: NICE guidelines on antiepileptic drugs—Antiepileptic drugs for seizures -The Joint Commission (TJC), 2015: Preventing falls and fall-related injuries in health care agencies—Fall prevention -The Joint Commission (TJC), 2019: National Patient Safety Goals—Patient identification

Safety Considerations

-Always check and confirm patient identification before any procedure. Use at least two patient identifiers (TJC, 2019). -In a health care setting, always keep a patient bed in the low position when unattended, and use the standard fall prevention strategies of the agency. If a patient is at high risk of falling, a bed alarm needs to be activated at all times. Options also include the use of a chair alarm in a recliner or wheelchair. -In the home setting, partner with the patient and family caregiver to conduct a home safety checklist -Be alert for conditions within a patient's environment that pose risks for injury (e.g., personal care items out of the patient's reach, hazards along walking paths, pets at home, electrical equipment not functioning correctly, liquid spilled on floors). -Use safe patient-handling techniques when transferring and assisting patients with ambulation to reduce the risk of a patient fall. -When seizure precautions are necessary, explain and demonstrate precautions to the patient and family caregiver.

The QSEN skills for safety competency include the following:

-Demonstrate effective use of technology and standardized practices that support quality and safety -Demonstrate effective use of strategies to reduce the risk of harm to self or others -Use appropriate strategies to reduce reliance on memory -Communicate observations or concerns related to hazards and errors to patients, families, and the health care team.

Fall Considerations include the following:

-Education of patients about fall risk factors and discussion regarding fall prevention strategies strengthens patients' knowledge of fall risks and participation in their own risk management (Huang et al., 2015). -Inform patients that the bedside is the most frequent location for falling in hospitals (Huang et al., 2015). -Clarify for patients the proper use of hospital equipment (e.g., crutches, wheelchairs) that can prevent falls (Huang et al., 2015). -The Joint Commission (2016) recommends all patients receive targeted education about their specific fall risks. -Tailor education to the patients' perceived risk of falls (Kuhlenschmidt et al., 2016).

Extrinsic Factors

-Frequency of rounding -Physical hazards: liquids on floor, electrical cords, compression stocking cords -Increased use of restraints -Footwear with greater heel height

Intrinsic Factors

-History of previous fall -Altered cognition -Altered Mobility -Lower Extremity weakness -Abnormal gait -Shuffling and stumbling -Requires assistance with mobility and/or assistive device -sensory deficit -Medications: Benzodiazepines, Antipsychotics, Antidepressants, Opiates, Barbiturates, Antihistamines, Anticonvulsants, Sedatives, Antihypertensives, Diuretic

Every year approximately ________ people in the United States fall in hospitals

700,000 to 1,000,000

Implement early mobility protocols within health care agency. Follow protocols to ensure patient increases level of mobility progressively. Consider use of accelerometers, small devices that can be worn by a patient and quantify biomechanical body movement and number of steps per shift.

A patient's functional decline (loss of the ability to perform self-care activities or activities of daily living) may result from deconditioning, which is associated with inactivity. Deconditioning is a risk for hospitalized patients who spend most of their time in bed, even when they are able to walk.

Use sitters or restraints only when alternatives are exhausted.

A sitter is a nonprofessional staff member or volunteer who stays in a patient room to closely observe patients who are at risk of falling. Restraints should be used only as a final option

Evaluate patient's ability to use assistive devices such as walker or bedside commode at different times during the day.

Adjustments in devices may become necessary. Evaluating at different times can help identify strengths and weaknesses

AHRQ

Agency for Healthcare Research and Quality

Activate a bed alarm for patient.

Alarm activates when patient rises off sensor. Alarm sounds alert to staff.

What do professional nurses engage in?

All activities that support a patient-centered safety culture. Provide compassionate and coordinated care based on respect for each patient's preferences, values, and needs.

Patient able to get out of bed independently: In four-side-rail bed, leave two upper side rails up. In two-side-rail bed, keep only one rail up.

Allows for safe exit from bed.

What is the sixth step when assessing someone for fall risk?

Ask patient or family caregiver if patient has a history of recent falls or other injuries within the home. Assess previous falls using the acronym SPLATT

What is the ninth step when assessing someone for fall risk?

Assess condition of equipment (e.g., legs on bedside commode, end tips on a walker)

What is the eighth step when assessing someone for fall risk?

Assess patient's fear of falling: consider those over 70 years of age, female, lower income, or single and have poor perceived general health

What is the fifth step when assessing someone for fall risk?

Assess patient's pain severity (use rating scale ranging 0 to 10).

Patient and/or family caregiver is able to identify fall risks.

Awareness of risks promotes cooperation and understanding of fall prevention plan.

Educate patients and family caregivers on medication side effects that increase risk for falls

Certain medications have side effects that alter a patient's balance, level of consciousness, and other factors and thus increase a patient's fall risk. Family caregivers need this information to reduce falls.

Complete an agency safety event or incident report noting objective details of?

Complete an agency safety event or incident report noting objective details of

Consider having patient wear protective headgear (e.g., oncology patient or patients at risk for bleeding) or hip protectors.

Contains impact-resistant material within the hat that surrounds the head and protects against head injury. Hip protectors have padding to reduce fall impact.

Be sure that wheelchair is correct fit for patient: Patient thighs are level while sitting, feet flat on floor; back of chair comes up to mid-shoulder, elbows rest on armrests without leaning over or tucking arms in, and two finger widths of space between patient and side of chair.

Correctly fitted chair promotes comfort, making it less likely for patient to try to exit it.

Transfer patient to wheelchair using safe handling techniques (see Chapter 17). Use a wedge cushion in chair (see illustration).

Cushion prevents patient from slipping out of chair.

Ask patient/family caregiver to identify patient's fall risks. Ask patient/family caregiver to describe fall prevention interventions to implement.

Demonstrates learning.

Use Teach-Back: "I want to be sure I explained clearly to you (example) why you are at risk for falls. Tell me some of those reasons." Revise your instruction now or develop plan for revised patient/family caregiver teaching if patient/family caregiver is not able to teach back correctly.

Determines patient's/family caregiver's level of understanding of instructional topic.

Provide patient's hearing aid and glasses. Be sure that each is functioning/clean (AHRQ, 2013). If patient complains of visual or hearing problems, refer to appropriate health care provider.

Enables patient to remain alert to conditions in environment.

Prioritize nurse call system responses to patients at high risk; use a team approach, with all staff knowing responsibility to respond.

Ensures rapid response by care provider when patient calls for help; decreases chance of patient trying to get out of bed on own.

American Epilepsy Society 2016

Evidence-based guideline: treatment of convulsive status epilepticus in children and adults—Treatment of status epilepticus

Confer with physical therapy about gait training, strength and balance training, and regular weight-bearing activities.

Exercise can reduce falls, fall-related fractures, and several risk factors for falls in individuals with low bone density and older adults (Berry and Kiel, 2018). Strength and balance training reduces the rate of injurious falls in older adults (Uusi-Rasi et al., 2015).

Arrange personal items (e.g., water pitcher, telephone, reading materials, dentures) within patient's easy reach and in logical way

Facilitates independence and self-care; prevents falls related to reaching for hard-to-reach items.

Patient does not experience a fall or injury.

Fall precautions successfully prevent falls.

Ensure adequate glare-free lighting; use a night-light at night.

Glare may be problem for older adults because of vision changes.

Patient's environment is free of hazards.

Hazards predispose to tripping and falls.

Adjust bed to low position with wheels locked. Place nonslip padded floor mats at exit side of bed.

Height of bed allows ambulatory patient to get in and out of bed easily and safely. Mats provide nonslippery surface for preventing falls and injuries.

What is the first step when assessing someone for fall risk?

Identify patient using at least two identifiers (e.g., name and birthday or name and medical record number)

What is the eleventh step when assessing someone for fall risk?

If patient is a fall risk, apply color-coded wristband. Some agencies institute fall risk signs on doors, whereas others may use color-coded socks or gowns.

What is the twelve step when assessing someone for fall risk?

If patient is in a wheelchair, assess his or her level of comfort, fatigue, boredom, mental status, or level of engagement with others.

Patient and/or family caregiver verbalizes understanding of fall prevention interventions to be planned.

Includes patient and family caregiver in decisions about preventive strategies.

Explain to patient/family caregiver when and why to use nurse call system (e.g., report pain, assistance needed to get out of bed or go to bathroom). Provide clear instructions regarding mobility restrictions.

Increases likelihood that patient/family caregiver will call for help and of nurse being able to respond to patient's needs in a timely way.

Patient safety

Is the prevention of physical and psychological harm to patients

Place nurse call system in an accessible location within patient's reach. Explain and demonstrate how to use system at bedside and in bathroom. Have patient perform return demonstration.

Knowledge of location and use of call system is essential for patient to be able to call for help quickly. Reaching for an object when in bed can lead to an accidental fall.

Consider use of a low bed that has lower height than standard hospital bed. Apply nonskid floor mats.

Low beds may reduce fall-related injuries. Low beds can make it difficult for patients with lower extremity weakness or pain in lower joints to exert effort needed to stand.

Place patient in a geri chair or wheelchair with wedge cushion. Use wheelchair only for transport, not for sitting for an extended time.

Maintains alignment and comfort and makes it difficult to exit chair

Evaluate for changes in motor, sensory, and cognitive status, and review if any falls or injuries have occurred.

May require different interventions to be added. Fall outcomes determine success of plan.

What is the QSEN safety competency stated as?

Minimizes risk of harm to patients and providers through both system effectiveness and individual performance

National Institute for Health and Care Excellence (NICE) 2014

NICE guidelines on antiepileptic drugs—Antiepileptic drugs for seizures

NICE

National Institute for Health and Care Excellence

The Joint Commission (TJC) 2019

National Patient Safety Goals—Patient identification

Orient patient to surroundings, nurse call system, and routines to expect in plan of care

Orientation to room and plan of care provides familiarity with environment and activities to anticipate.

Provide comfort measures, offer ordered analgesics for patients experiencing pain.

Pain can cause patients to exit bed; thus pain relief is essential. Be cautious because opioids increase fall risk.

Stay with patient during toileting (standing outside bathroom door).

Patients often try to get up to stand and walk back to their beds from the bathroom without help.

What is the third step when assessing someone for fall risk?

Perform hand hygiene. Assess for fall risks using a validated fall risk assessment tool. Compute fall risk score. Conduct a comprehensive individualized patient assessment and consider patient's unique fall risks. Perform a fall risk assessment in general acute care settings on admission, on transfer from one unit to another, or with a significant change in a patient's condition, or after a fall

What is the fourth step when assessing someone for fall risk?

Perform the Banner Mobility Assessment Tool (BMAT; Boynton et al., 2014) or the timed "get up and go" (TUG) test

The Joint Commission (TJC) 2015

Preventing falls and fall-related injuries in health care agencies—Fall prevention

Agency for Healthcare Research and Quality (AHRQ) 2013

Preventing falls in hospitals—Evidence-based interventions for fall prevention

Secure locks on beds, stretchers, and wheelchairs

Prevents accidental movement of devices during patient transfer.

Encourage use of properly fitted skid-proof footwear. Option: Place nonslip padded floor mat on exit side of bed.

Prevents falls from slipping on floor.

Back wheelchair into and out of elevator or door, leading with large rear wheels first

Prevents smaller front wheels from catching in crack between elevator and floor, causing chair to tip.

Establish elimination schedule, using bedside commode when appropriate.

Proactive toileting keeps patients from being unattended with sudden urge to use toilet.

Explain to patient and family caregiver reason for patient to use side rails: moving and turning self in bed.

Promotes a feeling of comfort and security. Aids in turning and repositioning and provides easy access to bed controls

Have assistive devices (e.g., cane, walker, bedside commode) on exit side of bed. Have chair back of a bedside commode placed against wall of room if possible.

Provides added support when transferring out of bed. Stabilizes commode.

Conduct hourly rounds on all patients to determine status of pain, need to toilet, and need to relocate personal items for easy reach; provide pain-relief intervention.

Provides nurses with surveillance mechanism to purposefully keep patients safe and comfortable by proactively meeting their needs.

What does QSEN stand for?

Quality and Safety Education for Nurses

Remove unnecessary supplies at bedside from patient room. Perform hand hygiene.

Reduces clutter. Reduces transmission of microorganisms.

Keep floors free of clutter and obstacles (e.g., intravenous [IV] pole, electrical cords), particularly path to bathroom

Reduces likelihood of falling or tripping over objects.

Remove excess equipment, supplies, and furniture from rooms and halls.

Reduces likelihood of falling or tripping over objects.

Provide privacy, be sure patient is comfortable, and prepare environment.

Reduces patient anxiety and facilitates an organized procedure.

Manage patient's pain, and do not allow him or her to sit in wheelchair for an extended amount of time; provide alternative sitting option.

Reduces restlessness and discomfort that can lead to wheelchair exit.

Schedule oral medication administration for at least 2 hours before "bedtime"

Reduces risk created by medications that can cause patients to have to use bathroom during night.

Coil and secure excess electrical, telephone, and any other cords or tubing.

Reduces risk of entanglement.

Clean all spills on floors promptly (Berry and Kiel, 2018). Post sign indicating wet floor. Remove sign when floor is dry (usually done by housekeeping).

Reduces risk of falling on slippery, wet surfaces.

Perform hand hygiene and gather equipment.

Reduces transmission of microorganisms and organizes care.

Explain what fall prevention measures you plan to provide in relation to patient's risks. Also plan for time to discuss fall prevention in the home

Results in fall prevention measures that are patient centered and not just routine. Younger patients are very independent and often believe that they are not likely to fall.

What is the second step when assessing someone for fall risk?

Review medical record and determine if patient has a recent history of a fall and risks for injury (ABCS) -age over 85 -bone disorders -coagulation disorders -surgery (specifically thoracic or abdominal surgery or lower limb amputation)

What is the seventh step when assessing someone for fall risk?

Review patient's medications (including over-the-counter [OTC] medications and herbal products) for drugs that create risk for falls

When ambulating patient, have patient wear a gait belt or walking sling, and walk along his or her side

Safe patient-handling techniques allow for safe patient ambulation and prevention of injury to you and patient.

Dependent, less mobile patients: In two-side-rail bed, keep both rails up. (NOTE: Rails on newer hospital beds allow for room at foot of bed for patient to safely exit bed.) In four-side-rail bed, leave two upper rails up

Side rails are restraint devices if they restrict a patient's freedom of movement and therefore do not promote the individual's independent functioning

What does SPLATT stand for?

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

Safety

The Institute for Healthcare Improvement defines it as freedom from accidental injury

TJC

The Joint Commission

Do not ask patient to provide a self-report of balance, gait, or ability to ambulate. Ask patient to walk a short distance using timed "get up and go," or complete the BMAT assessment and observe each factor. True or False?

True

What is the tenth step when assessing someone for fall risk?

Use patient-centered approach to determine what patient already knows about risks for falling. Show patient and family caregiver results of fall risk assessment, and explain significance of risk factors. Explain how a plan for fall prevention will be developed. Assess patient's or family caregiver's experience and health literacy level.

What does patient safety require

effective communication, teamwork, critical thinking, and timely clinical decisions.

extrinsic

health care agency environment and working process related

Patients are often more vulnerable to injury due to changes related to?

illness, such as fatigue, visual alterations, or lower extremity weakness.

The risk factors for falls include two categories:

intrinsic, extrinsic

multifactorial

many different conditions can contribute to a single patient fall

The skill of assessing and communicating a patient's risks for falling cannot be delegated to

nursing assistive personnel (NAP)

One patient population at high risk for falls with injuries is

oncology patients

Once a patient's fall risks are identified, a nurse's responsibility is to?

partner with the patient to affirm those risks and to select evidence-based interventions (usually multiple strategies) that appropriately target the patient's risks

intrinsic

patient related

Research shows that education of patients about fall prevention and activities associated with falling increases their awareness of the potential of falling and promotes what?

patient safety

Toileting is a common event leading to a

patient's fall

The most common risk assessment tools used in health care agencies are

the Morse Fall Scale, the STRATIFY scale, and the Hendrich II Fall Risk Model

Hospitalized patients are at risk for injury partly as a result of?

unfamiliar environments

Patient found after falling.

• Call for assistance. • Assess patient for injury, and stay with him or her until help arrives. • Notify primary health care provider and family caregiver. • Complete an agency occurrence or sentinel event report (see agency policy). • Conduct a postfall huddle/debrief as soon as possible after the fall. Involve staff at all levels and the patient if possible. Discuss whether appropriate interventions were in place, considerations as to why fall occurred, staffing at time of fall, which environment-of-care factors were in place, and how care plan will change (TJC, 2016).

The nurse directs the NAP by:

• Explaining a patient's specific fall risks and associated prevention measures needed to minimize risks • Explaining environmental safety precautions to use • Explaining specific patient behaviors (e.g., disorientation, wandering) that are precursors to falls and that should be reported to the registered nurse (RN) immediately

Patient starts to fall while ambulating with nurse or other caregiver.

• Put both arms around patient's waist or grasp gait belt. • Stand with feet apart to provide broad base of support. • Extend one leg and let patient slide against it to floor (Fig. 4.1A). Use caution because patient weight can cause hyperextension of your knee. • Bend knees and lower body as patient slides to floor (see Fig. 4.1B).

equipment needed for fall prevention

• Standardized and valid fall risk assessment tool (Berry and Kiel, 2018; TJC, 2016) • Hospital bed with side rails; Option: low bed • Wedge cushion • Nurse call system • Gait belt for assisting with ambulation • Wheelchair and seat belt (as needed) • Optional safety devices: bed alarm pad, no-slip floor mat, protective headgear, hip protector

Evidence-Based Fall Prevention Interventions in Health Care Settings

• Universal fall precautions, including scheduled rounding protocols (AHRQ, 2013) • Familiarize the patient with the environment. • Have the patient demonstrate call system use. • Be sure nurse call system is accessible to patient. • Keep the patient's personal possessions within patient's safe reach. • Have patient use sturdy handrails in patient bathrooms, room, and hallway. • Place the hospital bed in low position when a patient is resting in bed; raise bed to a comfortable height when the patient is transferring out of bed. • Keep hospital bed brakes locked. • Keep wheelchair wheel locks in locked position when stationary. • Keep nonslip, comfortable, well-fitting footwear on the patient (Berry and Kiel, 2018). • Use night-lights or supplemental lighting. • Keep floor surfaces clean and dry. Clean up all spills promptly. • Keep patient care areas uncluttered. • Follow safe patient-handling practices. • Care planning and interventions that address the identified risk factors within the overall care plan for the patient (AHRQ, 2013) • Encourage patients with sensory deficits to use eyeglasses, hearing aids, footwear, and mobility devices. • Institute toileting and comfort rounds based on patient need (Berry and Kiel, 2018). • Review patient's individual medications, and provide interventions that minimize risks created by medication side effects. • Encourage early mobility with appropriate assistance. • Consider use of rooms designated for cognitively impaired patients requiring (1) closer supervision and (2) specialty equipment and activities. • Assess patient risk for orthostatic hypotension, and assist patient to get out of bed safely. • Provide patient and family education regarding patient's unique fall risks (Berry and Kiel, 2018).