Safety

Nursing Actions

• Use risk assessment tools to evaluate clients and their environment for safety.

• Encourage clients to speak up and take an active role in their health care and in preventing errors.

• Create a culture of checks and balances to avoid errors when working in stressful circumstances.

• Communicate risk factors and plans of care to clients, family, and other staff.

• Use protocols for responding to dangerous situations.

• Adopt quality care priorities from the National Quality Forum, including “Never Events.”

• Use current evidence to promote a culture of safety, while using the National Patient Safety Goals as a guide.

• Know the facility’s disaster plan, understand the chain of command and roles, and use common terminology when communicating with the team.

• Identify and document incidents and responses according to the facility’s policy. These reports help identify trends, patterns, and the root cause of adverse events. 

• Know the location of safety data sheets and hazardous chemicals in the environment.

• Use equipment only after adequate instruction and safety inspection.

Falls

• Older adult clients can be at an increased risk for falls due to decreased strength, impaired mobility and balance, improper use of mobility aids, unsafe clothing, environmental hazards, endurance limitations, and decreased sensory perception.

• Other clients at increased risk include those with decreased visual acuity, generalized weakness, urinary frequency, gait and balance problems (cerebral palsy, injury, multiple sclerosis), and cognitive dysfunction. Adverse effects of medications (orthostatic hypotension, drowsiness) can also increase the risk for falls.

• Clients are at greater risk for falls when they have more than one risk factor.

• Prevention of client falls is a major nursing priority. Nurses must evaluate all clients in health care facilities for risk factors for falls and implement preventative measures accordingly.

• Programs to prevent falls are essential for settings that provide services to older adult clients.

• Health care facilities must actively prevent falls, especially because Medicare and Medicaid no longer reimburse for treating injuries resulting from falls

  Preventing Falls

  • Complete a fall-risk assessment for each client at admission and at regular intervals. Individualize the plan for each client according to the results of the fall-risk assessment. For example, instruct a client who has orthostatic hypotension to avoid getting up too quickly, to sit on the side of the bed for a few seconds prior to standing, and to stand at the side of the bed for a few seconds prior to walking.

  • Be sure the client knows how to use the call light (by giving a return demonstration), that it is in reach, and to encourage its use.

  • Respond to call lights in a timely manner.

  • Use fall-risk alerts (color-coded wristbands).

  • Provide regular toileting and orientation of clients who have cognitive impairment.

  • Provide adequate lighting.

  • Orient clients to the setting to make sure they know how to use all assistive devices (grab bars) and can locate necessary items.

  • Place clients at risk for falls near the nurses’ station.

  • Provide hourly rounding.

  • Make sure’ bedside tables, overbed tables, and frequent-use items (telephone, water, facial tissues) are within reach.

  • Keep the bed in the low position and lock the brakes.

  • For clients who are sedated, unconscious, or otherwise compromised, keep the side rails up.

  • Avoid the use of full side rails for clients who get out of bed or attempt to get out of bed without assistance.

  • Provide nonskid footwear and nonskid bath mats for use in tubs and showers.

  • Use gait belts and additional safety equipment when moving clients.

  • Keep the floor clean, dry, and free from clutter with a clear path to the bathroom (no scatter rugs, cords, or furniture).

  • Keep assistive devices nearby after validation of safe use (eyeglasses, walkers, transfer devices).

  • Educate the client and family about safety risks and the plan of care. Clients and family who are aware of risks are more likely to call for assistance.

  • Lock the wheels on beds, wheelchairs, and carts to prevent them from rolling during transfers or stops.

  • Use electronic safety monitoring devices (chair or bed sensors) for clients at risk for getting up without assistance to alert staff of independent ambulation.

  • Report and document all incidents. This provides valuable information that can help prevent similar incidents.

    A nurse is caring for a client who fell at a nursing home. The client is oriented to person, place, and time and can follow directions. Which of the following actions should the nurse take to decrease the risk of another fall?

    -Make sure that the client’s call light is within reach.

    -Complete a fall-risk assessment.

    -Provide the client with nonskid footwear.

A nurse is caring for a client who has a history of falls. Which of the following actions is the nurse’s priority?

-Complete a fall-risk assessment.

Seizures

A seizure is a sudden surge of electrical activity in the brain. It can occur at any time due to epilepsy, fever, or a variety of medical problems. Partial seizures (also called focal seizures) are due to electrical surges in one hemisphere of the brain, and generalized seizures involve both hemispheres of the brain. Status epilepticus (a prolonged seizure) is a medical emergency.

Seizure Precautions

Seizure precautions (measures to protect clients from injury during a seizure) are imperative for clients who have a history of seizures that involve the entire body and/or result in unconsciousness. QS

• Make sure rescue equipment is at the bedside, including oxygen, an oral airway, suction equipment, and padding for the side rails. Clients at high risk for generalized seizures should have a saline lock in place for immediate IV access.

• Ensure rapid intervention to maintain airway patency.

• Inspect the client’s environment for items that could cause injury during a seizure and remove items that are not necessary for current treatment.

• Assist clients at risk for seizures with ambulation and transferring to reduce the risk of injury.

• Advise all caregivers and family not to put anything in the client’s mouth (except an airway for status epilepticus) during a seizure.

• Advise all caregivers and family not to restrain the client during a seizure but to lower the client to the floor or bed, protect their head, remove nearby furniture, provide privacy, put them on one side with the head flexed slightly forward if possible, and loosen their clothing.

During a Seizure

• Stay with the client, and call for help.

• Maintain airway patency and suction PRN. ​​​​​​​

• Administer medications.

• Note the duration of the seizure and the sequence and type of movements.

• After a seizure, determine mental status and measure oxygenation saturation and vital signs. Explain what happened, and provide comfort, understanding, and a quiet environment for recovery.

• Document the seizure with any precipitating behavior and a description of the event (movements, injuries, duration of seizures, aura, postictal state), and report it to the provider.

nurse manager is reviewing with nurses on the unit in the care of a client who has had a seizure. Which of the following statements by a nurse requires further instruction?

-“I will go to the nurses’ station for assistance."

Seclusion and Restraint

• Nurses must know and follow federal, state, and facility policies for the use of restraints.

• Some clients require seclusion rooms and/or restraints.

• In general, use seclusion or restraints for the shortest duration necessary and only if less restrictive measures are not sufficient. They are for the physical protection of the client or the protection of other clients or staff.

• Clients can voluntarily request temporary seclusion if the environment is disturbing or seems too stimulating.

• Restraints can be either physical (devices that restrict movement: vest, belt, mitt, limb) or chemical (sedatives, neuroleptic or psychotropic medications) to calm the client.

• Restraints can cause complications, including pneumonia, incontinence, and pressure injuries.

• It is inappropriate to use seclusion or restraints for:

  • Convenience of the staff

  • Punishment for the client

  • Clients who are extremely physically or mentally unstable

  • Clients who cannot tolerate the decreased stimulation of a seclusion room

• Restraints should:

  • Never interfere with treatment

  • Restrict movement as little as is necessary

  • Fit properly and be as discreet as possible

  • Be easy to remove or change

• When all other less restrictive means have failed to prevent a client from harming themselves or others (orientation to the environment, supervision of a family member or sitter, diversional activities, electronic devices), the following must occur before using seclusion or restraints.

  • The provider must prescribe seclusion or restraints in writing, after a face-to-face assessment of the client.

    In an emergency situation when there is immediate risk to the client or others, nurses can place restraints on a client. The nurse must obtain a prescription from the provider as soon as possible according to the facility’s policy.

    • The prescription must include the reason for the restraints, the type of restraints, the location of the restraints, how long to use the restraints, and the type of behavior that warrants using the restraints.

    • The prescription allows only 4 hr of restraints for an adult, 2 hr for clients ages 9 to 17, and 1 hr for clients younger than 9 years of age. Providers can renew these prescriptions with a maximum of 24 consecutive hours.

    • Providers cannot write PRN prescriptions for restraints.

Nursing Responsibilities for Clients in Restraints

• Explain the need for the restraints to the client and family, emphasizing that the restraints keep the client safe and are temporary.

• Ask the client or guardian to sign a consent form.

• Review the manufacturer’s instructions for correct application.

  • Assess skin integrity, and provide skin care according to the facility’s protocol, for example every 2 hr.

  • Offer food and fluid.

  • Provide a means for hygiene and elimination.

  • Monitor vital signs.

  • Offer range-of-motion exercises of extremities.

• Pad bony prominences to prevent skin breakdown.

• Secure/tie restraints to a part of the bed frame that can raise and lower when the bed controls are used.  Do not secure/tie restraints to the side rails of the bed. If restraints with a buckle strap are not available, use a quick-release knot to tie the strap.

• Make sure the restraints are loose enough for range of motion and that there is enough room to fit two fingers between the restraints and the client.

• Remove or replace restraints frequently to ensure good circulation to the area and allow for full range of motion to the limbs.

• Conduct an ongoing evaluation of the client.

• Regularly determine the need to continue using the restraints. QS​​​​​​​

• Never leave the client alone without the restraints.

• Check facility policy regarding types of restraints. Many facilities no longer use vest restraints due to the risk for strangulation.

Document

• Precipitating events and behavior of the client prior to seclusion or restraints

• Alternative actions to avoid seclusion or restraints

• Time of application and removal of the restraints

• Type of restraints and location

• The client’s behavior while in restraints

• Type and frequency of care (range of motion, neurologic checks, removal, integumentary checks)

• Condition of the body part in restraints

• The client’s response at removal of the restraints

• Medication administration

Fire Safety

Fires in health care facilities are usually due to problems with electrical or anesthetic equipment, or from smoking.

All staff must:

• Know the location of exits, alarms, fire extinguishers, and oxygen shut-off valves.

• Make sure equipment does not block fire doors.

• Know the evacuation plan for the unit and the facility.

Fire response follows the RACE sequence

R: Rescue and protect clients in close proximity to the fire by moving them to a safer location. Clients who are ambulatory can walk independently to a safe location.

A: Alarm: Activate the facility’s alarm system and then report the fire’s details and location.

C: Contain/Confine the fire by closing doors and windows and turning off any sources of oxygen and any electrical devices. Ventilate clients who are on life support with a bag-valve mask.

E: Extinguish the fire if possible using the appropriate fire extinguisher.

Fire Extinguishers

To use a fire extinguisher, use the PASS sequence.

P: Pull the pin.

A: Aim at the base of the fire.

S: Squeeze the handle.

S: Sweep the extinguisher from side to side, covering the area of the fire.

Classes of fire extinguishers:

Class A is for combustibles (paper, wood, upholstery, rags, other types of trash fires).

Class B is for flammable liquids and gas fires.

Class C is for electrical fires.

Class D is for metals/metal shavings.

Class K is for kitchen fires involving fats and oils.

Class A,B,C is a multipurpose fire extinguisher that can be used for fires involving combustibles, flammable liquids, and electrical equipment.

A nurse observes smoke coming from under the door of the staff’s lounge. Which of the following actions is the nurse’s priority?

-Move clients who are nearby.