Safety

Big Picture

Safety = preventing injury before it happens.

For CJE questions, think:

What could hurt the patient first?
→ falls
→ aspiration
→ seizures
→ fire/electrical injury
→ self-harm
→ medication effects
→ environmental hazards

Core CJE Rule

Prevent the most immediate, serious, and likely harm first.

Use:

ABCs → unstable before stable → actual before potential → acute before chronic → least restrictive intervention first

1. Fall Risk

A fall risk is a patient with increased likelihood of falling because of physical, cognitive, medication, or environmental factors.

Major Fall Risk Factors

• History of previous falls

• Older age

• Weakness

• Unsteady gait

• Dizziness

• Confusion/delirium

• Dementia

• Poor vision

• Impaired hearing

• Urinary urgency/frequency

• Orthostatic hypotension

• Sedating medications

• Recent surgery/anesthesia

• Mobility impairment

• Use of assistive devices

• Muscle weakness

• Foot problems

• IV tubing/drains

• Unfamiliar environment

Critical Thinking

A patient can become a new fall risk even if they were previously independent.

Examples:

• New opioid

• New benzodiazepine

• Postoperative anesthesia

• New antihypertensive

• Acute confusion

• New weakness

CJE Cue

If the patient suddenly becomes:

• dizzy

• confused

• weak

• sedated

• hypotensive

→ reassess fall risk.

2. Fall Prevention

Basic Nursing Interventions

• Bed in lowest position

• Wheels locked

• Call light within reach

• Frequently used items within reach

• Adequate lighting

• Clear pathways

• Nonskid footwear

• Assist with transfers/ambulation

• Use prescribed walker/cane

• Encourage slow position changes

• Toilet patient regularly

• Respond promptly to call light

• Orient confused patients frequently

• Use bed/chair alarms when indicated

• Keep glasses/hearing aids available

High-Risk Patients

Use more supervision, not just more equipment.

Example:

A confused patient repeatedly climbing out of bed needs:

• frequent rounding

• toileting

• reorientation

• closer observation

—not simply four side rails.

CJE Trap

A fall-risk bracelet or sign does not prevent falls by itself.

The nurse must implement actual safety interventions.

3. Bed Safety

Safe Bed Setup

• Bed low

• Wheels locked

• Call light accessible

• Personal items accessible

• Pathway clear

• Appropriate side rails used

• Bed alarm if ordered/indicated

Never

Leave the bed high after providing care.

CJE Rule

After completing bedside care:

Lower the bed before leaving the patient.

4. Side Rails

Side rails are often tested because they can be either:

• a safety device

• OR a restraint

depending on how they are used.

Appropriate Uses

Examples:

• Prevent accidental rolling

• Assist repositioning

• Seizure precautions

• Stretcher transport

Four Side Rails

Raising all four side rails can be considered a restraint if it prevents the patient from getting out of bed voluntarily.

Why It Can Be Dangerous

A confused patient may:

• climb over the rails

• fall from a greater height

• become trapped

Better Approach

Use:

• lowest bed position

• appropriate number of rails

• frequent rounding

• bed alarm

• toileting

• observation

CJE Trap

More side rails ≠ more safety.

5. Call Light Placement

Call light must be:

Within the patient’s reach.

Especially important for:

• fall-risk patients

• weak patients

• postoperative patients

• visually impaired patients

• mobility-impaired patients

Before Leaving the Room

Ask:

• Is the bed low?

• Are wheels locked?

• Is the call light reachable?

• Are personal items reachable?

6. Nonskid Footwear

Patients ambulating should wear:

• nonskid socks

• properly fitting shoes

• nonslip footwear

Avoid walking in:

• regular socks

• loose slippers

• bare feet when unsafe

Why?

Reduces slipping and improves stability.

7. Clutter / Environmental Hazards

Common hazards:

• Electrical cords

• IV tubing

• Furniture in pathway

• Spills

• Rugs

• Poor lighting

• Equipment blocking walkway

• Loose objects on floor

Nursing Action

Remove hazards before ambulation.

CJE Priority

If the patient is about to walk and you see a spill:

Remove/avoid the hazard before helping the patient walk.

8. Home Safety

Assess:

• Lighting

• Stairs

• Rugs

• Handrails

• Bathroom safety

• Medication organization

• Smoke detectors

• Electrical cords

• Emergency access

• Mobility equipment

Important Home Fall Prevention

• Remove loose rugs

• Secure cords

• Install stair railings

• Use adequate lighting

• Keep pathways clear

• Use nightlights

• Avoid slippery floors

• Store frequently used items within easy reach

9. Bathroom Safety

Bathrooms are major fall-risk areas because of:

• Wet floors

• Slippery surfaces

• Transfers

• Toileting urgency

• Standing from low toilet seats

Safety Measures

• Grab bars

• Nonslip bath mats

• Shower chair

• Raised toilet seat when appropriate

• Adequate lighting

• Call system in hospital bathroom

• Assist high-risk patients

Important

Do not tell a high-risk patient:

“Just hold onto the towel rack.”

Towel racks are not designed as grab bars.

10. Older-Adult Safety

Older adults have increased risk due to:

• Reduced vision

• Hearing loss

• Slower reflexes

• Muscle weakness

• Balance changes

• Osteoporosis

• Polypharmacy

• Orthostatic hypotension

• Cognitive changes

• Chronic diseases

Major Concern

A fall in an older adult can cause:

• Hip fracture

• Head injury

• Loss of independence

• Hospitalization

Critical Thinking

Do not assume all older adults are confused or dependent.

Individualize interventions.

11. Medication-Related Fall Risk

Many drugs increase falls.

High-Yield Medication Groups

Sedatives

• Benzodiazepines

• Sleep medications

Cause:

• sedation

• slowed reaction time

• impaired balance

Opioids

Can cause:

• sedation

• dizziness

• hypotension

Antihypertensives

Can cause:

• hypotension

• orthostatic hypotension

Diuretics

Can increase:

• urinary urgency

• nighttime toileting

• dehydration

• hypotension

Antidepressants/Antipsychotics

May cause:

• sedation

• dizziness

• orthostatic hypotension

CJE Rule

If a patient receives a medication that causes sedation or hypotension:

Reassess their safety/fall risk.

12. Orthostatic Hypotension Precautions

Orthostatic hypotension = blood pressure falls when changing position.

Common symptoms:

• Dizziness

• Lightheadedness

• Weakness

• Blurred vision

• Syncope

Prevention

Teach patient to change positions slowly:

lying → sit → dangle → stand

Allow time between each step.

Other interventions:

• Assist with ambulation

• Ensure hydration if appropriate

• Encourage patient to sit if dizzy

• Keep call light within reach

CJE Priority

If patient becomes dizzy while standing:

Sit or lie the patient down first.

Do not keep walking them.

13. Seizure Precautions

Goal:

Prevent injury and maintain airway.

Before Seizure

For high-risk patient:

• Bed low

• Side rails appropriately padded per policy

• Oxygen available

• Suction available

• IV access if prescribed

• Remove environmental hazards

During a Seizure

DO

• Protect head

• Lower patient to floor if possible

• Turn patient to side

• Loosen restrictive clothing

• Remove nearby objects

• Time the seizure

• Maintain privacy

DO NOT

• Restrain patient

• Hold limbs down

• Place anything in mouth

• Force mouth open

Huge CJE Rule

Never put anything in the mouth during a seizure.

They cannot “swallow their tongue.”

After Seizure

Priority:

Airway + breathing

• Side-lying position

• Assess respirations

• Assess oxygenation

• Suction if needed

• Reorient patient

• Assess for injuries

• Document duration and characteristics

Critical Finding

Seizure lasting ≥5 minutes or repeated seizures without recovery may indicate status epilepticus → emergency.

14. Aspiration Precautions

Aspiration = food, fluid, saliva, or gastric contents entering the airway.

High-Risk Patients

• Stroke

• Dysphagia

• Decreased LOC

• Neurologic disorders

• Sedation

• Tube feeding

• Weak gag reflex

Prevention

• Elevate HOB

• Sit upright for meals

• Assess swallowing

• Small bites/sips

• Slow feeding

• Follow prescribed diet consistency

• Keep patient upright after meals

• Suction available when indicated

If Swallowing Ability Is Uncertain

Keep patient NPO until swallowing is evaluated.

Especially after stroke.

Signs of Aspiration

• Coughing during meals

• Choking

• Wet/gurgling voice

• Drooling

• Respiratory distress

• Decreased oxygen saturation

• Crackles

• Fever later

CJE Trap

A patient who has had a stroke should not automatically receive water or oral medication before a swallow screen/evaluation.

15. Suicide / Self-Harm Safety Basics

Safety is the immediate priority.

High-Risk Cues

• Suicidal statements

• Specific plan

• Access to lethal means

• Previous attempt

• Giving away possessions

• Sudden calmness after severe depression

• Hopelessness

Most Important Assessment

Ask directly:

• Are you thinking about harming yourself?

• Do you have a plan?

• Do you have access to the means?

Important

Asking about suicide does not cause suicide.

High-Risk Patient Safety

May require:

• Continuous observation

• Removal of harmful objects

• Safe environment

• Following institutional suicide precautions

Remove possible hazards such as:

• Sharps

• Belts

• Cords

• Medications

• Glass

• Weapons

CJE Rule

Do not leave a patient with active suicidal intent alone.

16. Fire Safety

Major hospital fire risks include:

• Oxygen

• Electrical equipment

• Smoking

• Flammable materials

Two acronyms are essential:

RACE

Used when there is a fire.

R — Rescue

Remove anyone in immediate danger.

A — Alarm

Activate fire alarm/call emergency system.

C — Contain

Close doors/windows if appropriate to contain fire/smoke.

E — Extinguish/Evacuate

Extinguish small fire if safe or evacuate.

Order

Rescue → Alarm → Contain → Extinguish/Evacuate

17. PASS

Used to operate a fire extinguisher.

P — Pull

Pull the pin.

A — Aim

Aim at base of fire.

S — Squeeze

Squeeze handle.

S — Sweep

Sweep side to side.

CJE Tip

Aim at the base of the fire, not the flames.

18. Oxygen Safety

Oxygen supports combustion.

It does not explode by itself, but it makes fires burn faster and hotter.

Safety Rules

• No smoking

• Keep away from flames

• Keep away from sparks

• Post oxygen-in-use signs

• Keep equipment functioning properly

• Secure oxygen cylinders

• Avoid petroleum-based products

Petroleum Products

Do not use petroleum jelly around oxygen equipment.

Use appropriate water-based products instead when needed.

Oxygen Cylinders

Store:

• Upright

• Secured

• Away from heat

CJE Trap

Smoking near oxygen is an immediate safety hazard.

19. Electrical Safety

Nursing Responsibilities

Inspect equipment before use.

Do not use equipment with:

• Frayed cords

• Exposed wires

• Broken plugs

• Loose connections

If defective:

Remove from service and report according to facility policy.

Do not attempt to repair it yourself.

Wet Areas

Water + electricity = shock risk.

Avoid:

• Plugging in equipment with wet hands

• Electrical equipment near water

• Using damaged devices

High-Yield CJE Safety Priorities

Critical Thinking / Reasoning Facts

1. The safest intervention is not always the most restrictive intervention.

Example:

Confused fall-risk patient

❌ four side rails + restraints immediately
✅ low bed + observation + frequent rounding + toileting + bed alarm

2. Fix immediate danger before education.

Example:

Patient smoking while oxygen is running.

First:

Stop/remove the immediate fire hazard.

Education comes after safety is restored.

3. Assessment comes first unless there is an obvious immediate threat.

Example:

Patient reports dizziness after standing.

You do not perform a long assessment while they remain standing.

First:

Sit them down.

Then assess.

4. A change from baseline is often more important than the diagnosis.

An independent patient who suddenly becomes confused and unsteady is now at significant fall risk.

5. Equipment alone does not make a patient safe.

• Side rails

• bed alarms

• fall bracelets

are supplements, not replacements for nursing observation and intervention.

CJE “Needs Follow-Up” Red Flags

Immediately question these:

• “I raise all four side rails for every fall-risk patient.”

• “I put something between the teeth during a seizure.”

• “I restrain the patient’s arms during a seizure.”

• “A stroke patient can drink water if they are awake.”

• “A suicidal patient can be left alone if they promise not to hurt themselves.”

• “Petroleum jelly is safe around oxygen.”

• “The patient can hold the towel rack when getting out of the shower.”

• “I leave the bed elevated because it is easier for staff.”

• “A dizzy patient should keep walking until the feeling passes.”

All of those are unsafe.

One CJE Safety Chain to Remember

Recognize danger → remove/protect from danger → stabilize → assess → intervene further → reassess.

That logic will answer a lot of safety questions even when the exact scenario looks unfamiliar.