Ch 12-13 Safety and Patient Safety Topics Notes
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Topic header indicates chapters: Ch 12 - Client Safety/Restraints / Seizures; Ch 13 Home Safety.
Source: Copyright 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins.
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National Patient Safety Goals (NPSG) and Standards of Compliance were initiated in 2002 by The Joint Commission (TJC).
Purpose: Identify established safety practices that health care institutions should accomplish.
Most organizations routinely practice these goals; they are cataloged into a register of adopted "Standards of Compliance" that must be met consistently.
There are now over 250 standards of compliance.
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National Safety Goals are newly created and approved each year.
They are endorsed based on national adverse events and sentinel events observed in health care facilities.
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National Patient Safety GoalsⓇ (Effective January 2025 for the Hospital Program)
Goal 1: Improve the accuracy of patient identification. Code: ext{NPSG.01.01.01}
Use at least two patient identifiers when providing care, treatment, and services.
Rationale: Wrong-patient errors occur at virtually all stages of diagnosis and treatment. The goal has two aims: reliably identify the individual and match the service/treatment to that individual.
Newborns are at higher risk of misidentification due to inability to speak and lack of distinguishable features; examples include misidentification leading to wrong patient/wrong procedure or feeding breastmilk to the wrong newborn.
A reliable identification system among all staff is necessary to prevent errors.
Ep 1, EP 2, EP 3 (examples of performance elements):
Use at least two identifiers when administering medications, blood or blood components; when collecting samples; and when providing treatments or procedures. Do not use room number as an identifier. (Refer to MM.05.01.09, EPS 7, 10; PC.02.01.01, EP 10)
Label containers for blood and other specimens in the presence of the patient. (Refer to PC.02.01.01, EP 10)
Use distinct methods of identification for newborn patients.
Practical examples for identifiers: using mother's name + newborn gender (e.g., "Smith, Judy Girl" and "Smith, Judy Girl A/B" for multiples); standardized ID bands (two body sites and/or barcoding); staff communication tools to alert about newborns with similar names.
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NPSG: Identify Clients Correctly
Two components to identifying clients accurately:
Use two client identifiers and ensure that the medication, treatment, procedure, or care is intended for that specific client.
Client identifiers may include: client’s name, date of birth, designated hospital number, telephone number, or alternative client-specific documentation.
All providers/nurses must verify, per facility policy, the client with two ID methods. This two-step process affirms correct identification for the given care.
When possible, ask open-ended questions (e.g., What is your name and date of birth?) and confirm identity with ID bracelet or electronic medical record.
Use barcode scanning and other technologies as additional safety features.
Under no circumstances should the client’s assigned room be used for identification.
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Client Identifiers (examples):
Client's name
Date of birth
ext{Medical record number}
Photo ID (driver's license, passport, picture)
Telephone number
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Types of Unexpected Events
Client Safety Event: Broad umbrella term for any unplanned/unexpected occurrence during patient care that could have resulted in harm. Includes near misses, adverse events, and sentinel events.
Near Miss: Event or situation that could have caused harm but did not due to chance, early detection, or timely intervention. Key: No harm occurred.
Example: A nurse prepares the wrong medication but a second nurse double-checks and catches the error before administration.
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Adverse Event: Patient safety event resulting in unintended harm due to medical management (care that caused harm) rather than the patient’s underlying condition.
Key: Harm occurred, but not necessarily severe or permanent.
Example: Pressure injury from inadequate turning; mild allergic reaction due to incorrect medication administration.
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Sentinel Event: Serious, unexpected adverse event involving death, permanent harm, or severe temporary harm requiring intervention to sustain life.
Key: Severe outcome; often qualifies as a signal for immediate investigation (Root Cause Analysis, RCA).
Examples: Wrong-site surgery; patient suicide in a facility; fall with hip fracture and permanent disability; hemolytic transfusion reaction.
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Summary of severity progression:
Near Miss: Error occurred, no harm.
Adverse Event: Error occurred with some harm.
Sentinel Event: Error occurred with severe harm or death, prompting in-depth analysis.
Client Safety Event: Broadest category including all above and any other safety-related events.
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Occurrence (Incident or Variance) Report
A tool used to report an adverse event, sentinel event, client safety event, or near miss.
Action plans are created to help prevent future occurrences.
Examples of reportable items:
Accident or injury of a client, staff member, or visitor (e.g., fall)
Unexpected vaccine reaction
Unexpected drug reaction
Incorrect administration of a drug or vaccine
Damaged or lost items
Exposure to blood products
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Uses of the incident report:
Used for quality improvement and identifying risks.
Not used for disciplinary action against staff.
Must be completed after any accident or incident that compromises safety.
Describes circumstances of the accident/incident.
Details the patient’s response to examination and treatment after the incident.
Completed by the nurse immediately after the incident.
It is not part of the medical record and should not be mentioned in documentation.
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Age-Related Considerations
Infants and Preschoolers (0–4 Years)
School-Age Children (5–12 Years)
Adolescents (13–19 Years)
Adults (19 Years and Older)
Older Adults (65 Years and Older)
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Developmental Considerations #1: Neonate and Infant
Areas to monitor: fetal considerations, mobility, car seats.
Developmental Considerations #1: Toddler and Preschooler
Areas: environment, poisoning, asphyxiation, child abuse.
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Developmental Considerations #2: School Age and Adolescents
School Age: accidents, child abduction, bullying.
Adolescent: driving, substance use/misuse/abuse, piercings and tattoos, firearms, internet and social media, sex trafficking.
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Developmental Considerations #3: Adult and Older Adult
Adult: drug use and poisoning; intimate partner violence.
Older Adult: falls; motor vehicle accidents; fire; polypharmacy and poisoning; elder abuse.
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Safety Considerations for Older Adults
Identify safety hazards in the environment.
Modify the environment as necessary.
Attend defensive driving courses or courses designed for older drivers.
Encourage regular vision and hearing tests.
Ensure hearing aids and eyeglasses are available and functioning.
Have operational smoke detectors in place.
Objective documentation and reporting of any signs of neglect or abuse.
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Teaching About Home Safety
Remove items that could cause trips (e.g., throw rugs, loose carpets).
Place electrical cords and extension cords against a wall behind furniture.
Monitor gait and balance; provide aids as needed.
Ensure steps and sidewalks are in good repair.
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FIRE - R.A.C.E.
Rescue: Remove clients, visitors, and employees in immediate danger.
Alarm: Activate the emergency fire alarm per facility policy.
Contain: Close doors and windows to decrease the fire’s oxygen source.
Extinguish: Attempt to extinguish small fires if a proper extinguisher is available and safe to use.
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Fire Extinguisher - P.A.S.S.
Pull: Remove the pin to break the tamper-resistant seal.
Aim: Aim at the base of the fire; keep the extinguisher at the lowest point of the fire; for CO2 extinguishers beware of touching the plastic discharge horn.
Squeeze: Squeeze the handle to release contents at the base of the fire.
Sweep: Sweep the base of the fire from side to side until extinguished; ensure it does not reignite; repeat as needed.
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Falls
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Assessing Fall Risk in the Older Adult
Assess for history of falls or accidents.
Note assistive devices.
Be alert to history of drug or alcohol abuse.
Obtain knowledge of family support systems and home environment.
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Morse Fall Scale (MFS) (Adapted with permission, SAGE Publications)
Description: A rapid and simple method of assessing a patient’s likelihood of falling.
Widely used in acute care settings; quick assessment, often takes less than 3 minutes.
Structure: Six variables that are quick to score; has predictive validity and interrater reliability.
Items (six):
History of falling (immediate or within 3 months)
Secondary diagnosis
Ambulatory aid (bed rest/nurse assist; crutches/cane/walker; furniture)
IV/Heparin lock
Gait/Transferring (normal/bedrest/immobile; weak; impaired)
Mental status (oriented to own ability; forgets limitations)
Scoring: Total score indicates risk level (the scale has a defined cutoff where higher scores indicate greater fall risk; the maximum total is commonly cited as 125 in standard references).
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Factors That Contribute to Falls
Strength issues (lower body weakness)
Poor vision
Gait and balance issues
Problems with feet and/or shoes
Medications that increase fall risk (psychoactive)
Orthostatic hypotension (postural dizziness)
Home hazards (hazards in home and community)
Vitamin D deficiency (muscle weakness and bone health)
Comorbidities (neurological, cardiovascular, osteoporosis, glaucoma, cataracts, diabetic retinopathy, hearing impairments, diabetic neuropathy)
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Indications of a Concussion
Physical: headaches, vomiting, problems with balance, fatigue, dazed or stunned appearance
Cognitive: mentally foggy, difficulty concentrating and remembering, confusion, forgets recent activities
Emotional: irritability, nervousness, very emotional behavior
Sleep: drowsiness, difficulty falling asleep, sleeping more or less than usual
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Nursing Action When a Client Falls
Identify and document incidents and responses per facility policy to help identify trends, patterns, and root causes.
Ensure the client’s call light is within reach.
Keep the bed in its lowest position with 2–3 side rails up.
Provide nonskid footwear to the client.
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Seizure Caring for a Client Who Is Having a Seizure
During a Seizure:
Stay with the client and call for help.
Maintain airway patency and suction PRN.
Administer medications as ordered.
Note seizure duration and sequence/type of movements.
After a Seizure:
Determine mental status and measure oxygen saturation and vital signs.
Explain what happened and provide comfort, understanding, and a quiet recovery environment.
Document the seizure with precipitating behavior and a description of the event (movements, injuries, duration, aura, postictal state) and report to the provider.
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Restraints
Definition: Physical devices or chemical means used to limit a patient’s freedom and movement that cannot be easily removed by the patient. Chemical restraints are drugs used to control behavior not included in the person’s normal medical regimen.
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Action to Take Prior to the Use of Restraints
Explain the need for restraints to the client and family, emphasizing safety and temporary nature.
Obtain consent from the client or guardian.
Review the manufacturer’s instructions for correct application.
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Restraint Application Guidelines
Secure/tie restraints to a part of the bed frame that can move with bed controls; do not secure to side rails.
If using a buckle strap restraint, ensure it is secured; if buckle strap is unavailable, use a quick-release knot.
Restraints should be loose enough to allow ROM and to fit two fingers between restraint and client.
Cushion skin with padding to prevent skin breakdown.
Remove or replace restraints frequently to maintain circulation and ROM.
Perform skin care and assess skin integrity per facility protocol (e.g., every 2 hours).
Offer food and fluid; provide hygiene and elimination; monitor vital signs; perform ROM exercises.
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Ongoing Evaluation of Restraints
Regularly determine the need to continue restraints.
Never leave the client alone without restraints unless policy allows.
Check facility policy on types of restraints; many facilities no longer use vest restraints due to strangulation risk.
Restraints should be used as a last resort.
Discontinue at the earliest possible time.
Death from a restraint is a sentinel event.
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Emergency Use of Restraints
In emergencies with immediate risk, nurses can place restraints but must obtain a provider prescription as soon as possible per policy.
Prescription must include reason, type of restraints, location of restraints, duration, and behavior warranting use.
Maximum durations without renewal: 4\ hours for an adult, 2\ hours for ages 9–17, and 1\ hour for younger than 9.
Renewals: prescriptions can be renewed for a maximum of 24 consecutive hours.
PRN prescriptions for restraints are not allowed.
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Physiological Hazards Associated With Restraints
Increased risk of serious injury from falls
Skin breakdown
Contractures
Incontinence
Depression
Delirium
Anxiety
Aspiration and respiratory difficulties
Death
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Types of Restraints Used for Adults and Children
(Images/Examples referenced; no specific list provided in transcript.)
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Electrical Safety
Check that electrical cords are not frayed or severely creased.
All devices should have a grounded (three-pronged) plug.
Confirm that receptacles have three openings and that no sparking occurs.
Do not plug/unplug with wet hands or while in a wet area.
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Electrical Safety (continued)
Avoid rolling over electrical cords with beds or other equipment.
Unplug by grasping the plug, not the cord.
Avoid extension cords.
If a device is unsafe, tag and remove it; notify Clinical Engineering per policy.
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Maintaining Emergency Preparedness
Address biological threats, chemical threats, radiation threats, cyber terror.
Preparing for mass trauma terrorism, pandemic preparation.
Identifying disaster resources.
Addressing psychological aspects of disasters.
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Chemicals Used for Mass Destruction #1
Biotoxins
Blister agents/vesicants
Blood agents
Choking/lung/pulmonary agents
Blood agents (listed again, note duplication in transcript)
Incapacitating agents
Long-acting anticoagulants
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Chemicals Used for Mass Destruction #2
Metals
Nerve agents
Organic solvents
Riot control agents / tear gas
Toxic alcohols
Vomiting agents
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Question #1 (True/False): Among older adults, fires are the leading cause of injury fatality.
A. True
B. False
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Answer to Question #1: B. False
Rationale: Among adults, falls are the leading cause of injury fatalities.
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Question #2 (True/False): A nurse whose behavior is reasonable and prudent and similar to that expected of another nurse in similar circumstances is still likely to be found liable if a patient falls.
A. True
B. False
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Answer to Question #2: B. False
Rationale: If behavior is reasonable and prudent and aligns with standard practice, it is unlikely to be found liable when a fall occurs.
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Question #3 (True/False): A side rail is considered a restraint even if the patient asks for it to be raised to assist in getting into and out of bed.
True
False
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Answer to Question #3: B. False
Rationale: A side rail is not considered a restraint if the patient requests it to aid in getting in or out of bed; the patient must be able to raise/lower the side rail themselves.
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Question #4: Which action is a priority in the RACE acronym for fire safety?
A. Run to the nearest fire alarm.
B. Act calmly to prevent panic.
C. Confine the fire by opening doors and windows.
D. Evacuate patients and others to a safe area.
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Answer to Question #4: D. Evacuate patients and other people to a safe area
Rationale: RACE priorities are Rescue, Activate a code/Notify, Confine, Evacuate.
참notes for exam prep and cross-references:
The content emphasizes patient safety identification, safety event taxonomy (near miss, adverse, sentinel), and the process and ethics around incident reporting and non-punitive quality improvement.
Restraint use is framed as a last resort with strict procedural and safety requirements, including consent, proper application, ongoing evaluation, and rapid termination when no longer needed.
Fire safety follows RACE and fire extinguisher use follows P.A.S.S. protocols (hands-on practice recommended).
Falls risk assessment (Morse Fall Scale) is a core tool for older adults, with six quick items that combine into a total risk score to guide prevention strategies.
Home safety and home safety education focus on removing trip hazards, managing cords, gait/balance, environment maintenance, and ensuring functional vision/hearing aids.
The Q&A section at the end reinforces understanding of safety priorities, liability implications, and restraint policy nuances.
If you want, I can convert these notes into a printable PDF format or tailor them to specific exam questions (e.g., create a question bank with the above topics).