Patient Safety, Nurse Roles, Restraints & Developmental Safety Review

Session Road-Map

• Purpose of session: High-level review of safety fundamentals every nurse must master.
  • National Patient Safety Goals (NPSG) – “why” and “how”
  • Nursing role in injury / illness prevention & safe restraint use
  • Developmental-stage safety (fetus ➜ older adult)
  • Knowledge, Skills & Attitudes (KSA) for safe care
• Speaker encourages continuous Q&A – safety is everyone’s job.

Safety Applies To Whom?

• Patients – principle of non-maleficence (first, do no harm).
• Visitors – e.g., COVID-19 visitor limitations were a safety intervention.
• Staff – RN, LPN, MD, housekeeping, phlebotomy, engineering; a single unsafe worker endangers all.

National Patient Safety Goals (NPSG) – $2025$ Hospital Edition

• Published annually by The Joint Commission (TJC).
  • $24$th edition released; some years wording static, numbering changes.
• Crafted by multidisciplinary advisory committee (RN, MD, pharmacy, engineering, etc.).
• Driven by Sentinel Events – unexpected death or serious physical/psychological injury to pt/visitor.

Examples of Sentinel Events

• Falls with fracture or death.
• Retained surgical items / wrong-site surgery.
• Medication error causing severe harm (e.g., the Vanderbilt vecuronium case).
• Unexpected inpatient death (e.g., $40$-y-o with cellulitis).

Goals & Key Nursing Implications

1. Identify patients correctly – use two identifiers (best: name + medical-record number).
2. Improve staff communication – SBAR, read-back of critical labs, timely result reporting (< $45$ min for critical K$^+$).
3. Use medications safely – smart pumps, drug libraries; $23$ keystrokes vs 1 barcode scan.
4. Use alarms safely – bed & IV alarms on loudest/standard setting.
5. Prevent infection – hand hygiene, appropriate PPE, emerging pathogens (e.g., novel fungi).
6. Identify pt safety risks – universal suicide screening across settings.
7. Improve health-care equity – NEW $2025$; address outcome disparities (e.g., higher maternal mortality in African-American women).
8. Prevent surgical mistakes – time-outs, site marking, sponge/instrument counts.

Nurse-Specific System Contributions

• Professional organizations (e.g., NSNA, ANA) – lobbying for staffing ratios, legislative change.
• Research / QI participation – data collection, publication (student example published before graduation).
• NDNQI (National Database of Nursing Quality Indicators)
  • Founded $2005$ by ANA; acquired $2015$ by Press-Ganey.
  • Benchmarks nursing-sensitive outcomes: falls, pressure injuries, etc.
• Better hospital performance ⇨ better reimbursement & patient outcomes.

Everyday Bedside Actions that Reduce Harm

• Answer any call light – “That’s not my patient” is never acceptable.
• Help colleagues with turns/lifts; use ergonomic equipment.
• Positive attitude ➜ psychological safety; ask for & offer help.
• Adhere to Standard Precautions (assume all body fluids are infectious).
  • Gloves; eye/face shield when emptying urine; mask per policy.

Physical Restraints

• Last resort; require provider order (RN must know facility rules – MD, NP, PA signatures).
• Order valid $24$ h; pt must be re-evaluated before renewal.

Not Automatically a Restraint

• Mitts – allow full finger/arm ROM; not tied to bed.

Common Hospital Restraints

• 2- or 4-point limb straps
• Vest/belt
• Pediatric mummy wrap
• $4$ side-rails up = restraint (unless air-mattress or pt request documented).

Application Principles

• Secure to non-movable frame (not side-rail).
• Quick-release buckle or slip-knot.

Indications vs Contra-indications

• Indications: risk of self-harm, tube removal, violent towards self/others while intubated.
• Contra-indications: violent psych crisis needing behavioral restraints, skin breakdown at site.

Hazards

• Suffocation, impaired breathing/circulation, nerve injury, skin ulcers, de-conditioning, incontinence, worsened delirium.

Nursing Responsibilities

• Document precipitating behavior BEFORE application.
• Monitor q$30$ min – breathing, CSM(T).
• Release & ROM q$2$ h; meet toileting, food, fluid needs.
• Education – patient (as able) & family.

Alternatives / Least-Restrictive Measures

• Cause-oriented: treat hypoxia, pain, infection.
• Environmental: reduce noise/light, single-bed room.
• Diversion: music therapy, iPad/TV calming channels, dementia boxes, robotic pets.
• Family presence (24-h sitter during COVID exception).

Developmental Safety Considerations

Fetus

• Eliminate maternal teratogens: alcohol, tobacco, non-Rx drugs.
• Seat-belt below uterus; avoid radiation/pesticide exposure.
• Emphasize prenatal visits & nutrition (social-work referral prn).

Neonate (Birth–$28$ days)

• Room-in; never truly unattended (baby monitor).
• Hand hygiene for all visitors.
• Head/neck support.
• Car-seat rear-facing; no 2nd-hand seats (expiration, crash history).

Infant ($1$–$12$ mo)

• Close supervision; safe bath seating; never alone even in $2$ cm water.
• Lock cabinets, meds, cannabis edibles.
• Age-appropriate toys, choking checks (toilet-paper-roll test).
• Child-abuse vigilance.

Toddler ($1$–$3$ yr)

• Childproofing escalates (higher, sturdier).
• Gun safety: firearm locked, ammo stored separately.
• Fire/burn: pot-handle position, stove guards, anchored dressers/TVs.
• Water: pool fencing, ladder removal.

Preschool ($3$–$6$ yr)

• Helmet use (tricycle, bike with training wheels).
• Stranger-danger, traffic awareness.
• Car-seat with $5$-point harness until size/weight met.
• Begin simple fire-escape plan practice.

School-Age ($6$–$12$ yr)

• Booster seat until seat-belt fits (≈ $145$ cm, $36$ kg).
• Protective sports gear (soccer shin-pads, baseball helmets).
• Continued immunizations (compliance often drops here).
• Intro drug/alcohol & private-body-parts education.

Adolescent ($13$–$18$ yr)

• Peer-pressure ➜ tobacco, vaping, alcohol – motivational interviewing.
• MVA risk: driver-ed, no texting, seat-belts $100\%$.
• Suicide screening, bullying/cyberbullying.
• Sexual health: contraception & STI counseling.

Young Adult ($18$–$40$ yr)

• Stress management (school, job, family).
• Healthy diet/exercise – metabolism slows.
• Domestic violence recognition.
• Occupational hazards, OSHA compliance, sharps/radiation PPE.

Middle-Aged Adult ($40$–$65$ yr)

• “Sandwich generation” stress – dependent children & aging parents.
• Mod-vigorous exercise, BP/cholesterol screening.
• Alcohol moderation – risk ↑ with age.

Older Adult ($\ge 65$ yr)

• Falls – #1 cause of injury death >$65$.
  • Vision/hearing aids, night-lights, footwear.
• Med-polypharmacy & orthostatic hypotension.
• APS (Adult Protective Services) – fraud, financial abuse, neglect.
• Home safety eval: throw-rug removal, grab-bars, medication review.

Equipment & Environment Safety

• IV pumps – use full drug library, guardrails.
• Bed alarms – loudest setting; roommate comfort < patient safety.
• Side-rail policy – ≥$3$ up unless contraindicated.
• Radiation – staff badges, shielding, rotate assignments for pregnant workers.

Knowledge, Skills, Attitudes (KSA) for Safe Care

• Knowledge – Policy, EBP guidelines, pharmacology, pathophys.
• Skills – SBAR, med-admin $6$ rights, hand hygiene >90\% compliance, ambulation/transfer tech.
• Attitudes – safety culture, just-culture error reporting, teamwork, lifelong learning.

Ethical & Philosophical Points

• Autonomy vs Safety – restraints restrict freedom; use only when beneficence outweighs autonomy violation.
• Equity vs Equality – NPSG $2025$ calls for equitable (not just equal) care delivery.
• Transparency – sentinel-event disclosure & root-cause analysis support public trust.

Quick-Reference: Key Numbers & Facts

• $2$ patient identifiers (ideal: name + MRN).
• $24$ – 2025 NPSG edition; $8$ hospital goals.
• $23$ steps ➜ manual IV pump programming versus drug-library shortcut.
• Critical labs communicated < $45$ min.
• Restraint assessment q$30$ min; release q$2$ h; order expires $24$ h.
• $4$ raised side-rails = restraint (unless medically justified).
• Falls benchmarked by NDNQI; compare $10$ vs $60$ per month example.
• $5$-point harness until size/weight met; rear-facing ≥ $2$ y per AAP.
• $65$ + population: falls leading cause of fatal injury.

Take-Home Mantras

• “If it isn’t documented, it didn’t happen.”
• “If you can’t breathe, nothing else matters.”
• Safety is interdisciplinary, developmental, & continuous – own your part every shift.