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).
- 24th 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

Identify patients correctly – use two identifiers (best: name + medical-record number).
Improve staff communication – SBAR, read-back of critical labs, timely result reporting (< 45 min for critical K^+).
Use medications safely – smart pumps, drug libraries; 23 keystrokes vs 1 barcode scan.
Use alarms safely – bed & IV alarms on loudest/standard setting.
Prevent infection – hand hygiene, appropriate PPE, emerging pathogens (e.g., novel fungi).
Identify pt safety risks – universal suicide screening across settings.
Improve health-care equity – NEW 2025; address outcome disparities (e.g., higher maternal mortality in African-American women).
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 q30 min – breathing, CSM(T).
Release & ROM q2 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 q30 min; release q2 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.