S

Chapter 28 Safety, Security, and Emergency Preparedness – Study Notes

Chapter 28 Safety, Security, and Emergency Preparedness: Comprehensive Study Notes

  • Safety and security are basic human needs and foundational to nursing care.

    • Safety defined as freedom from danger, harm, or risk; responsibility of all health care providers.
    • IOM (To Err is Human, 2000) called for a renewed culture of safety; emphasis that many errors stem from system problems rather than individual fault.
    • Tools and evidence-based approaches exist to reduce errors and promote safer care (OSHA guidance, 2016).
    • Nurses are the largest health care workforce and have a pivotal role in shaping safety culture and patient outcomes.
    • ANA definition of a culture of safety: an organizational environment where core values and behaviors prioritize safety over competing goals, supported by leadership, managers, and staff (n.d.).
    • Key features of safety culture: high-risk awareness, blame-free reporting, teamwork and collaboration, and a systems-based perspective with resource commitment (HHS/AHRQ, 2019a).

  • Foundational framework and national action plan

    • IHI National Action Plan to Advance Patient Safety identifies four interconnected areas:
    1. Culture, leadership, and governance focused on safety,
    2. Patient and family engagement,
    3. Workforce safety and resilience using systems perspective,
    4. A network for continuous learning and information sharing.
    • Plan ties person-centered care, systems thinking, and population health to patient safety improvements.

  • Course context and QSEN reflective practice

    • QSEN Reflective Practice box highlights ethical, legal, and safety decision-making through real-world case (e.g., Juanita Flores and infant Inez).
    • SELF-REFLECTION prompts guide learners to examine:
    • Personal accountability, reporting timelines, and alignment with institutional policies,
    • The impact of culture of safety on patient well-being,
    • How to engage patients and families as partners in safety,
    • Documentation, informatics, and teamwork in safety events.

  • Person-centered vs. systems-based safety in practice

    • Person-centered safety focuses on individual patients’ needs, environment, development, mobility, sensory perception, communication, health state, and psychosocial state.
    • Systems-based safety focuses on organizational processes, workforce, technology, policies, and cross-disciplinary collaboration.
    • Population-based safety extends safety thinking to communities and public health (emergency preparedness, violence prevention, injury prevention).

  • Emergency preparedness and national security context

    • Since 9/11 and subsequent events, nurses are integral to emergency response, including biologic, chemical, radioactive threats.
    • IHI four foundational areas tie to emergency readiness and continuous learning in safety culture.
    • National and global readiness: NDMS, FEMA, CDC HAN, Joint Commission safety standards, Red Cross, DHS resources, and public health surveillance networks.

  • Reflective practice and ethical/legal skills (QSEN section)

    • Real-world ethical dilemmas in safety reporting (e.g., unreported infant fall) illustrate balance between accountability and non-punitive reporting.
    • BOXES and prompts explore:
    • When to report safety events,
    • How to balance patient safety, professional integrity, and institutional policy,
    • The role of incident reporting in quality improvement and learning.

  • Core nursing competencies in safety, security, and emergency preparedness

    • Nursing concepts introduced: Medical Emergencies, Safety, Health Policy, Violence, Communication.
    • Safety is contextual across home, workplace, community, and health care facilities.
    • The nurse’s role spans prevention, screening, teaching, and advocating for safer environments.

  • Developmental considerations: risk by life stage

    • Neonate/Infant considerations include fetal exposures and safe sleeping practices; newborns require patent airway protection and infection prevention.
    • Mobility considerations evolve from immobility to exploration; hazards include small objects, hot liquids, and climbing hazards.
    • Car seats and travel safety: rear-facing seats to height/weight limits; booster seats until height ~4'9'' (about 145 cm) and weight thresholds; front seat airbags risk; ensure tight harnesses.
    • Universal prevention messaging targets each developmental era with stage-appropriate teaching points.

  • Teaching Tips 28-1: Preventing accidents at varying developmental stages

    • Fetus: fetal growth risks; avoid alcohol, smoking, and environmental hazards; prenatal care importance.
    • Neonate/Infant: keep infants supervised, crib rails, avoid small objects; crib safety; infant car seat usage; safe sleep position.
    • Toddler/Preschooler: hazard-proof home; supervision; childproofing; poison safety; car seats; water/supervision near water.
    • School-Age: helmet use, safety with sports, bike safety, and safe driving messages for older youths.
    • Adolescent: risks from motor vehicle crashes, guns, substances, bullying, social media safety, sexuality education, mental health.
    • Adult: stress, domestic violence, workplace safety; driving and occupational hazards; pain management and safe health practices.
    • Older Adult: falls risk, vision/hearing changes, polypharmacy, elder abuse, fire safety, home safety assessment.

  • Neonate/Infant and child safety specifics

    • Fetal considerations: nicotine, alcohol, drug exposure risks at birth; prenatal visits and vitamins.
    • Mobility and home safety: never leave infant unattended; crib rails; hot liquids and sharp objects out of reach; pacification of choking hazards (toilet paper tube test for small parts).
    • Car seats: rear-facing until manufacturer limits; forward-facing with five-point harness; booster seats until height
      ightarrow 4'9''; avoid front seats due to airbags; tighten harnesses.
    • Poisoning prevention and home safety: keep PCC number accessible; locking medicines; childproof cabinets; poison control counseling.
    • Poisoning treatment in ED: stabilization; absorption prevention; activated charcoal (most effective), not for home use; syrup of ipecac not recommended; gastric lavage not routine.

  • Environmental safety, home and workplace factors

    • Home safety checklist components: smoke detectors, fire extinguishers, escape plans, stop, drop, and roll, safe storage, childproofing, poison control, CO detectors, furnace inspection.
    • Electrical safety: cords, outlets, space heaters, no overload of outlets, unplug unused devices; safety of microwaves for children.
    • Fire safety: CO detectors, safe heating sources, no smoking in bed; safe handling of hot liquids; water heater temperature below 120^ ext{o}F.
    • Poisoning prevention: color-coded medication bottles, avoid syrup of ipecac, home decontamination not advised, PCC contact.
    • Falls prevention (home): clear paths, lighting, handrails, nonslip surfaces, consider hip/knee strategies, childproofing; supervision and safe play environments.

  • Adolescent safety and risk: driving, substances, bullying, and digital risks

    • Driving: adolescence is primary risk for motor vehicle crashes (age 16-19); graduated driver licensing (learner, intermediate, unrestricted).
    • Distracted driving: most common teen distractions pre-crash include passengers, cell phone, looking outside, etc.; long-term trends show rising distraction usage.
    • Substance use: 2018 SAMHSA data: alcohol use among 12–17-year-olds; binge drinking; underage drinking prevalence; illicit drugs usage.
    • Tobacco and vaping: 2018 data show high school current tobacco use; vaping rising; nicotine exposure risks.
    • Illicit and designer drugs: MDMA, fentanyl analogues, NBOMe, synthetic cannabinoids; rising availability and risks.
    • Pierscings and tattoos: infection risks; regulatory guidance from FDA; post-care importance for infection control.
    • Firearms: US firearm mortality patterns in children; gun safety and education; public health approach to responsible ownership and storage.
    • Internet and social media: online safety risks; meeting online strangers; cyberbullying; privacy and digital literacy; reporting suspected exploitation (FBI/CyberTipline).
    • Sex trafficking risk: identification and reporting under the Justice for Victims of Trafficking Act; demographics and relationships to traffickers; importance of community engagement.
    • IPV teen dating violence (TDV): prevalence and consequences; LGBTQ+ considerations and power dynamics; assessment tools (E-HITS) and safety planning.
    • Emotional and mental health impacts: bullying consequences; somatic symptoms; school performance effects; need for supportive relationships and school-based prevention.

  • Adult safety considerations and substance misuse

    • Underage drinking: persistent health risks; public health statistics; zero-tolerance enforcement and school/community prevention strategies.
    • Illicit drug use among teens; transition to adulthood; opioid and stimulant misuse trends; overdose deaths in 2018: 67{,}367 drug poisoning deaths (unintentional 87.4 ext{%}, suicides 7.2 ext{%}, etc.).
    • Designers drugs and synthetic substances; NBOMe, 2C-B, fentanyl analogues, bath salts, synthetic cannabinoids; safety education required for adolescents and families.

  • P ika: Piercings and tattoos—health risks and regulatory landscape

    • Piercings: infection risks and potential for chronic infections and tissue damage; need for professional, sterile environment.
    • Tattoos: risks similar to piercings; potential complications with MRI; toxicity concerns with pigments; FDA stance on regulation.
    • Teen consent considerations; post-procedural care essential.

  • Firearms safety and counseling

    • Firearm deaths among children: high-income countries comparison; US burden; gun ownership correlates with risk of home injuries and domestic homicide.
    • Counseling focus: safety, storage, child access prevention; public health approach to reduce injuries and deaths; integration with Healthy People objectives.

  • Internet/cyber risks and information literacy

    • Online behavior risks: stalking, online sexual exploitation, financial exploitation; importance of filtering software, account monitoring, and exchange of access with parents.
    • Online postings are public and persistent; privacy management and online literacy required.
    • Reporting and cyber safety resources (FBI/CyberTipline) and the role of parents in monitoring.

  • Adolescent and adult health risks related to violence and abuse

    • IPV and TDV prevalence: lifetime exposure; intersectionality considerations (race, gender identity, LGBTQ status).
    • Safety planning for victims: steps for staying safe at home, in relationships, with children, and during pregnancy.
    • Elder abuse and its consequences: physical, psychological, financial; role of family context; importance of private conversations and interprofessional support.

  • Older adult safety priorities and fall prevention

    • Falls: major cause of injury and hospital admission in >65; hip fracture costs: roughly 50 billion annually (Medicare/Medicaid share 75
      ightarrow 75f exttt{
      }}
    • STEADI algorithm for fall risk screening, assessment, and intervention (Table 28-1; Fig. 28-1) and nursing responsibilities.
    • Key modifiable risk factors: gait/balance, strength, vision, footwear, orthostatic hypotension, medications, vitamin D deficiency, home hazards.
    • Assessment tools: Timed Up & Go, 30-Second Chair Stand, 4-Stage Balance Test; Snellen chart for vision; Beers Criteria review of medications.
    • Interventions: physical therapy, home safety evaluation, vitamin D supplementation, community-based exercise programs, hydration, cataract considerations, environmental modifications, and assistive devices.

  • Falls in the health care facility (inpatient and long-term care)

    • Fall prevention programs required by Joint Commission; sentinel events and never events in CMS lists; documentation and RCA requirements.
    • Tools: Hendrich II Fall Risk Model (with Get Up and Go); Morse Fall Scale; staff training and clinical protocols to reduce falls.
    • Restraints in health care: historical perspective; reduction of restraint use (ANA position, 2012); least restrictive approaches; side rails and alternatives; emergency use of restraints requires orders post-event.
    • Box 28-5 and 28-6 summarize nursing interventions and ANA recommendations; emphasis on alternatives to restraints and patient rights.

  • Restraints and ethical practice

    • Restraints should be last resort; always consider least restrictive options; involve family in decisions; consent when required (long-term care contexts).
    • Documentation: when restraints are used, document alternatives attempted, patient assessment, consent, and ongoing monitoring; ensure routine nurse/patient reassessment and re-evaluation of need.
    • Potential adverse outcomes of restraints: skin breakdown, respiratory compromise, delirium, dehydration, cognitive decline, and patient distress.
    • Quick-release mechanisms and safe attachment practices to prevent injury when restraints are used.

  • Environmental safety in health care settings

    • RACE protocol for fires: Rescue, Activate, Confine, Evacuate; use ABC extinguishers; maintain safe alarm and hazard response.
    • Alarm management and noise control: reducing alarm fatigue; improving hospital soundscape; balancing patient safety with environmental noise.
    • Equipment safety: proper use of devices, three-prong plugs, avoiding overloading outlets; regular maintenance and reporting of malfunctioning equipment; device-specific safety checks.
    • Procedure-related safety: patient identification, time-outs, adherence to protocols; avoiding medication/IV errors; correct handoffs and communication.
    • National Patient Safety Goals (Joint Commission): ongoing updates; evidence-based targets to prevent sentinel events; demonstration of compliance in accreditation.

  • Safety event reporting and documentation

    • Safety Event Report (incident report): confidential, not part of the patient’s medical record; used for learning and root cause analysis; immediate and accurate objective description required.
    • Post-incident communication with patient/family; transparency and accountability; differential legal implications by state.

  • Population-based safety and community health

    • Population health focus: engaging with communities to reduce injuries and violence; importance of WISQARS for injury data; interventions designed through collaborative partnerships across public health and clinical care.
    • Role of school nurses in safety education: fire safety, vision/hearing screening, firearms safety, bullying prevention, and emergency preparedness planning.
    • School nutrition programs and policies: Healthy, Hunger-Free Kids Act; school meal programs and policy implications for safety and nutrition.

  • Environmental pollutants and public health safety

    • Air pollution and climate change links to respiratory and cardiovascular disease; environmental health hazards in urban areas; proactive safety and advocacy by nurses.

  • Community violence and firearm safety

    • Violence prevention packages by CDC; safe environments, community security measures, and personal safety planning.

  • Emergency preparedness resources and planning (Table 28-3)

    • National Disaster Medical System (NDMS): federal response coordination; supports state/local health departments.
    • FEMA: broader national emergency management coordination.
    • CDC: disease prevention and health protection; Health Alert Network (HAN) dissemination.
    • The Joint Commission: accreditation standards and safety guidance.
    • American Red Cross: safety information and disaster response.
    • DHS: national security and public safety coordination.

  • Bioterrorism, chemical, radiologic, and cyber threats

    • Biologic agents: anthrax, botulism, brucellosis, plague, smallpox, tularemia, viral hemorrhagic fevers; clinical manifestations vary and require standard precautions plus specific interventions and PPE.
    • Chemical threats: multiple categories (biotoxins, vesicants, blood agents, caustics, choking/lung/pulmonary agents, incapacitating agents, long-acting anticoagulants, metals, nerve agents, organic solvents, riot control agents, toxic alcohols, vomiting agents).
    • Radiation threats: nuclear terrorism risks; radiation burns and organ injury; decontamination and protection for responders.
    • Cyber threats: cyberspace security risks; hospital network vulnerabilities; importance of cybersecurity literacy in health care teams.
    • Nurse roles in cyber/biologic/chemical disasters include rapid assessment, decontamination, triage, and coordination with emergency responders.

  • Mass trauma and disaster preparedness

    • Disaster planning requires collaboration among internal hospital committees and external partners; mass casualty events require triage and resource allocation.
    • CDC and public health networks support rapid information sharing, stockpiling of essential medications, and rapid deployment of responders.
    • Pandemic preparedness highlights the need for resilient health systems, gas masks/ventilation strategies, testing and contact tracing capacity, and clear communication with the community.

  • Preparing for mass trauma and pandemic response: practical nursing roles

    • Nurses as frontline responders: triage, clinical care, counseling, and distribution of resources during disasters.
    • The importance of ongoing education and preparedness drills; ethical and legal considerations during disasters.
    • The ANA and other professional bodies provide guidance on professional conduct and safety during mass events (e.g., Ebola, COVID-19).

  • Home health safety and community care planning

    • Home safety assessments should identify floor hazards, wires, clutter, lighting, and fire safety readiness; ensure smoke detectors and CO detectors are present and functional.
    • Fire safety at home includes escape planning, safe heating sources, and regulations around space heaters and smoking.
    • Firearm safety in the home requires patient and caregiver education about storage and access.
    • Violence prevention and safety planning for vulnerable populations (elderly, disabled, LGBTQ+ individuals).

  • Practical study tips and exam preparation pointers

    • Be able to identify developmental risk factors, apply STEADI and fall risk assessment tools, and justify interventions.
    • Recognize when to implement restraints (last resort) and when to choose alternatives; understand legal/ethical frameworks and documentation requirements.
    • Know key national resources and guidelines for safety, emergency preparedness, and disaster response.
    • Be prepared to assess, plan, implement, and evaluate safety interventions across home, community, and health care settings.

  • Quick NCLEX-style review highlights

    • Identify high fall risk indicators: age >65, history of falls, postural hypotension, unfamiliar environment.
    • Fire safety teaching should emphasize that most home fire deaths occur during sleep and are caused by smoke inhalation; smoke detectors save lives.
    • Appropriate car seat progression and safety testing (Booster Fit Test) for children; back seat is safest for older children.
    • IPV screening tools (E-HITS) and safety planning for victims; include LGBTQ considerations in assessment and intervention planning.
    • Restraint use: only as a last resort, with orders and continuous monitoring; prefer alternatives (electronic alarms, reorientation, environmental modification).
    • Handling of safety events: complete safety event reports promptly; communicate with patients and families openly.

  • Connections to practice and real-world relevance

    • Culture of safety links to daily nursing practice, leadership decisions, and patient outcomes.
    • Population health and community partnerships expand the impact of safety beyond individual patients to families, schools, and communities.
    • Emergency preparedness and disaster response require interprofessional collaboration, resource planning, and ethical consideration in high-stress situations.

  • Ethical, philosophical, and practical implications

    • Balancing patient autonomy with safety (e.g., side rails, restraints) requires patient-centered decision-making and vigilant risk assessment.
    • Transparency and reporting in safety events promote learning and system improvement, but may raise concerns about punitive consequences; the goal is a blame-free, diagnostic approach to prevent recurrence.
    • Equity considerations in safety (e.g., disparities in drowning risk, firearm injuries, elder abuse) necessitate targeted interventions and inclusive policies.

  • Formulas, numerical references, and units (examples)

    • Age thresholds and risk ranges: >65 years for older adult fall risk; 16-19 years as high-risk adolescent driver group.
    • Injury statistics and counts:
    • Drug poisoning deaths in 2018: 67{,}367 (unintentional, suicides, etc.)
    • Adolescent alcohol use and binge drinking data (2018): various percentages; exact figures are provided in the CDC/SAMHSA references.
    • Height/weight benchmarks for child car seats: booster seat until height 4'9'' and weight range 80-100 ext{ lb}.
    • Temperature safety: water heater set to 120^ ext{o}F$$ maximum.
    • Vitamin D and calcium supplementation is shown to reduce fall risk in older adults (CDC references).

  • Summary takeaway

    • Safety in nursing is a multi-layered concept spanning person-centered care, systems thinking, and population health.
    • Effective safety work requires ongoing education, vigilant assessment, collaborative teamwork, evidence-based interventions, and robust emergency preparedness planning.
    • The nurse’s role is proactive and preventive: anticipate hazards, educate patients and families, implement safety strategies, monitor outcomes, and engage in continuous quality improvement.

  • Suggested quick review prompts

    • What are the four foundational areas of the IHI National Action Plan to Advance Patient Safety?
    • How does STEADI guide fall risk assessment in older adults? Name two core assessment tools.
    • What are the key features of a culture of safety as defined by ANA?
    • When is the use of restraints appropriate, and what are the required documentation steps?
    • List three major categories of threats covered in disaster preparedness (biologic, chemical, radiologic) and one nurse action for each.

  • References to chapters, boxes, and figures (for exam cross-referencing)

    • Box 28-1 Home Safety Checklist; Box 28-2 Manifestations of Child Maltreatment; Box 28-3 Safety Belt Fit Test; Box 28-4 E-HITS IPV Screening Instrument; Box 28-5 Nursing Interventions to Prevent Falls in a Health Care Facility; Box 28-6 ANA Position Statement on Restraints.
    • Figure 28-1 STEADI algorithm; Figure 28-2 Nurse safety education poster; Figure 28-3–28-5 device and restraint illustrations.
    • Table 28-1 Fall Risk Factors; Table 28-2 Biologic Agents (referenced in disaster planning); Table 28-3 Emergency Preparedness Resources.

  • Note on exam-style practice (from Text material)

    • The chapter includes numerous practice questions and answer rationales to reinforce safety planning, fall risk assessment, home safety, IPV screening, and disaster response decision-making.

  • Closing thought

    • Safety, security, and emergency preparedness are ongoing professional commitments for nurses, requiring vigilance, compassion, and evidence-based action across all settings and life stages.