Leadership Chapter 4 - Maintaining a Safe Environment
Culture of Safety
Promotes openness and error reporting, fostering a blame-free environment where healthcare professionals feel safe to report errors, near misses, and adverse events without fear of punishment. This leads to a deeper understanding of systemic issues rather than individual blame.
Aims to result in lower numbers of adverse events by identifying root causes and implementing preventative measures and system improvements.
Risk Management departments help identify and prevent adverse events, hazards, track the occurrence of negative client incidents, and help manage hazards by analyzing trends and developing strategies for risk reduction.
Events that are reported/tracked under Risk Management include:
Service occurrences (relate to client services and may include a delay in service or unsatisfactory service, e.g., delay in administering medication, wrong meal delivered).
Near misses – Patient negative outcome (accident, illness, or injury) almost occurs but is prevented by chance or timely intervention (e.g., a medication error caught before administration).
Serious incidents – resulting in minor injuries requiring intervention (e.g., a client fall causing a bruise), loss of equipment or property, or a significant service interruption. These usually require internal investigation.
Sentinel events – unexpected death or major permanent loss of function (whether physical or psychological) not related to the client’s illness, or situations where there was a direct risk of either. A thorough, major investigation (root cause analysis) is required by regulatory bodies (e.g., The Joint Commission). Examples include:
Major loss of function or death not expected with client’s medical condition.
Client attempted suicide during around-the-clock care.
A hemolytic transfusion reaction (e.g., ABO incompatibility).
Wrong site or wrong client surgical procedure.
Rape within a healthcare facility.
Infant abduction.
Discharge of an infant or child to the wrong family.
Failure to rescue (most serious) – occurs when a client develops a complication (e.g., sepsis, respiratory arrest) that leads to death, where client indicators (vital signs, clinical symptoms) were missed, misinterpreted, or acted upon too late by one or more healthcare personnel who should have recognized and addressed the complication promptly. This signifies a breakdown in the care process.
QSEN competencies in nursing
Focus: Quality and safety of health care in the US, developed by the Quality and Safety Education for Nurses (QSEN) initiative to prepare future nurses with the knowledge, skills, and attitudes (KSAs) necessary for continuous quality improvement and safe patient care.
Data from Joint Commission consistently identify poor communication as a key contributing factor in the majority of sentinel events, highlighting the importance of effective interprofessional communication.
1) PATIENT-CENTERED CARE: Providing caring and compassionate, culturally sensitive care that respects and addresses the client’s physiological, psychological, sociological, spiritual, and cultural needs, preferences, and values. This includes involving the client and their family in care decisions.
2) TEAMWORK AND COLLABORATION: Functioning effectively within nursing and inter-professional teams, fostering open communication, mutual respect, and shared decision-making to achieve continuity of care and positive client outcomes. Key elements include SBAR communication and handoff reports.
3) EVIDENCE-BASED PRACTICE: Integrating the best current evidence with clinical expertise and client/family preferences and values for delivery of optimal health care. This involves using current knowledge from credible research and other credible sources on which to base clinical judgement and client care.
4) QUALITY IMPROVEMENT: Using data to monitor outcomes of care processes and using improvement methods to design and test changes to continuously improve the quality and safety of health care systems. This involves care-related and organizational processes that include the development and implementation of a plan to improve health care services and better meet client needs.
5) SAFETY: Minimizing risk of harm to clients and providers through system effectiveness and individual performance. This involves minimization of risk factors that cause injury or harm while promoting quality care and maintaining a secure environment for clients, self, and others.
6) INFORMATICS: Using information and technology to communicate, manage knowledge, mitigate error, and support decision making. This includes the use of information technology as a communication and information-gathering tool that supports clinical decision-making and scientifically-based nursing practice.
Handling Infectious and Hazardous Materials
INFECTION CONTROL: Essential to prevent cross-contamination of communicable organisms (e.g., bacteria, viruses) and health care-associated infections (HAIs), which are infections acquired during healthcare delivery.
Staff education on infection prevention and control is a primary responsibility of the nurse, ensuring continuous competency in aseptic techniques, hand hygiene, and transmission-based precautions.
Facility policies and procedures are a crucial resource for all healthcare team members, providing detailed guidelines for infection control practices specific to the institution.
Clients with known or suspected communicable disease (e.g., tuberculosis, C. difficile, influenza) should be placed in the appropriate isolation based on the mode of transmission (airborne, droplet, contact).
Nurses should ensure appropriate equipment (e.g., PPE like masks, gowns, gloves, eye protection) is available and that isolation procedures are properly carried out by ALL healthcare team members, including ancillary staff and visitors.
Use STANDARD PRECAUTIONS (tier one precautions) for ALL clients, regardless of diagnosis or presumed infection status. These include:
Hand hygiene: Before and after client contact, after contact with blood/body fluids, after glove removal. Facilities should provide resources for employees to perform hand hygiene (alcohol-based hand rubs or soap and water) in client care areas.
Personal Protective Equipment (PPE): Use gloves, gowns, masks, eye protection as appropriate for anticipated exposure to blood, body fluids, secretions, excretions, non-intact skin, and mucous membranes.
Respiratory hygiene/cough etiquette: Covering mouth/nose when coughing/sneezing, hand hygiene, spatial separation.
Safe injection practices: Using aseptic technique for parenteral medications.
Sterile instruments/devices: Proper cleaning, disinfection, and sterilization of reusable client care equipment.
A latex-free environment is provided for clients with latex allergy to prevent anaphylactic reactions.
Use moisture-resistant bags for disposing of soiled items (e.g., linens, dressings), tying them securely to prevent leakage and contamination; only double bag if the outside of the bag becomes visibly contaminated or specified by facility policy.
Use safety needles or needless IV systems to prevent needlestick and sharps injuries, which are common causes of healthcare worker infections.
Dispose of sharps (e.g., needles, scalpels, broken glass) in puncture-resistant sharps containers immediately after use at the point of care, ensuring containers are not overfilled.
Report any needlesticks or sharps exposures per facility policy and state law; an incident/occurrence report should be filed promptly to initiate post-exposure prophylaxis and follow-up.
Four levels of precautions:
STANDARD PRECAUTIONS: Applies to all patients, all the time.
AIRBORNE PRECAUTIONS: For diseases transmitted by small airborne droplets (e.g., tuberculosis, measles, varicella). Requires a private room with negative pressure airflow, N95 respirators for personnel, and surgical masks for patient transport.
DROPLET PRECAUTIONS: For diseases transmitted by large droplets (e.g., influenza, mumps, pertussis). Requires a private room or cohorting, surgical mask within 3 ext{ feet} of the patient.
CONTACT PRECAUTIONS: For diseases transmitted by direct or indirect contact (e.g., C. difficile, MRSA, VRE, RSV). Requires a private room or cohorting, gloves, and gown upon entry to the room.
Health care team must clean and maintain equipment shared by clients on a unit (e.g., vital sign equipment, stethoscopes) between each client use using appropriate disinfectants.
Keep designated equipment (e.g., blood pressure cuff, stethoscope) in the rooms of clients on contact precautions to prevent cross-contamination to other areas.
Hazardous materials
Nurses and other staff are at significant risk for exposure to hazardous materials including chemicals (e.g., chemotherapy agents, cleaning solutions), biological agents (e.g., bloodborne pathogens), and radioactive materials.
Employees have the right to refuse to work in hazardous conditions if there is a clear health threat, as outlined by OSHA regulations.
Follow OSHA (Occupational Safety and Health Administration) guidelines: These federal regulations provide a safe work environment free from recognized hazards that can cause death or serious harm to employees.
Make protective gear (e.g., impermeable gowns, face shields, double gloving, respirators) accessible and mandatory for hazardous conditions (e.g., handling antineoplastic medications, working with sterilization chemicals).
Provide measurement devices (e.g., dosimeters for radiation exposure) and keep accurate records of an employee’s exposure over time (e.g., radiation from x-rays, chemical exposures) to monitor long-term health risks.
Provide comprehensive education and recertification opportunities regarding handling hazardous materials, including proper disposal procedures and emergency response.
Have a Safety Data Sheets (SDSs) manual (formerly Material Safety Data Sheets-MSDS) readily available in every workplace. These sheets provide critical safety information for each chemical product, including:
Toxicity (health hazards).
Handling and storage procedures.
First aid measures in case of exposure.
Containment procedures for spills.
Personal protective equipment required.
Designate an institutional HAZMAT response team trained to handle spills, exposures, and other incidents involving hazardous materials effectively and safely.
Safe use of equipment
Refers to appropriate operation of health care equipment by trained staff to prevent injuries from malfunction, disrepair, or mishandling, ensuring patient and staff safety.
Nurses’ responsibilities:
Learn to use and maintain competency in equipment use through training, reading manuals, and seeking guidance. Never operate unfamiliar equipment.
Check equipment at the beginning and during the shift (e.g., oxygen tanks for sufficient levels and proper flow, nasogastric suction for proper setting/function, IV pumps for correct rate) for proper setting/function and integrity.
Ensure electrical equipment is grounded (e.g., uses a 3 ext{-pronged} plug and is inserted into a grounded outlet) to reduce static electricity and the risk of electrical shock.
Ensure outlet covers are in place in environments with increased risks (e.g., pediatrics, psychiatric units) to prevent accidental shock or insertion of foreign objects.
Unplug equipment by grasping the plug itself (not the cord) to avoid bending prongs, fraying wires, or damaging the outlet.
Ensure life-support equipment (e.g., ventilators, IV pumps for critical medications) is plugged into outlets designated for backup generators during power outages, typically identified by "red" outlets.
Disconnect all electrical equipment prior to cleaning to prevent electrical shock or damage to the device.
Ensure all pumps (general infusion pumps and Patient-Controlled Analgesia (PCA) pumps) have free-flow protection mechanisms to prevent uncontrolled delivery of fluids or medications, which could lead to overdose.
Avoid overcrowded electrical outlets; use extension cords only when absolutely necessary (e.g., for temporary use, not as permanent wiring solutions) and ensure they are placed safely on the floor to prevent tripping hazards.
Use equipment only as intended and for its specific purpose. Modifications can lead to malfunction and injury.
Regularly inspect equipment by engineering/maintenance departments (e.g., annual preventative maintenance) and by the user prior to each use for signs of damage or malfunction.
Identify faulty equipment promptly by labeling it "Do Not Use" and reporting it to the appropriate department (e.g., Biomedical Engineering) for repair or replacement, removing it from service immediately.
Specific risk areas
Many factors affect a client’s ability to protect themselves from injury:
Age: Extremes of age (infants, older adults) have unique vulnerabilities.
Mobility: Impaired mobility (e.g., from stroke, surgery, weakness) increases fall risk.
Cognitive and sensory awareness: Impaired cognition (e.g., dementia, delirium) or sensory deficits (e.g., poor vision, hearing loss) limit ability to perceive and react to hazards.
Emotional state: Agitation, depression, or anxiety can affect judgment and decision-making regarding safety.
Lifestyle and safety awareness: High-risk behaviors (e.g., substance abuse, poor adherence to safety guidelines) or lack of knowledge about potential hazards.
Review facility protocol for managing high-risk situations (e.g., use of restraints, managing agitated clients, fire drills) to ensure consistent and safe responses.
Preventing injury is a major nursing responsibility, requiring continuous assessment, planning, intervention, and evaluation.
Falls prevention – a major nursing priority
Falls are a significant cause of injury and death, especially in older adults, and lead to increased healthcare costs and prolonged hospital stays.
Screen all clients for fall risk factors upon admission, regularly during their stay, and upon transfer.
Physiological changes related to aging: Decreased strength, impaired mobility/balance, endurance limitations, decreased sensory perception (e.g., proprioception), and changes in gait are common.
Evaluate incidence of client falls: Facilities track fall rates. A formula based on specific metrics, such as falls per 1,000 ext{ client days} (total falls / total client days * 1000), can be used to compare fall rates between facilities or over time to identify improvement areas.
Additional risk factors:
Decreased visual acuity (e.g., cataracts, glaucoma).
General weakness and deconditioning.
Orthopedic problems (e.g., diabetic neuropathy leading to loss of sensation in feet, arthritis causing pain and stiffness).
Urinary frequency or incontinence leading to rushed bathroom trips.
Gait/balance problems (e.g., Parkinson’s disease, osteoporosis affecting posture, arthritis affecting joint mobility).
Cognitive dysfunction (e.g., dementia, delirium, confusion) leading to impaired judgment.
Adverse medication effects (e.g., orthostatic hypotension from antihypertensives, drowsiness from sedatives, diuretics increasing frequency).
Clients with multiple risk factors are at significantly greater risk; those who have fallen previously are at a much higher risk for falling again.
Falls risk assessment (using validated tools like the Hendrich II Fall Risk Model or Morse Fall Scale) feeds into individualized prevention plans, tailoring interventions to the specific needs and risks of each client.
Falls prevention – plan individualized based on risk assessment
GENERAL MEASURES TO PREVENT FALLS:
Orient clients to their environment upon admission, ensuring they understand how to use all assistive devices (e.g., call light, walker, crutches) and can locate necessary items (e.g., bathroom, water, remote).
Place high-risk patients (e.g., confused, history of falls) in rooms near the nursing station for closer observation and quicker response.
Keep bedside tables, overbed tables, and frequently used items (e.g., phone, glasses, water) within easy reach to prevent clients from stretching or reaching unsafely.
Maintain bed in the lowest position when the client is resting or unattended to minimize impact in case of a fall out of bed.
Keep bed rails up for sedated/unconscious or compromised clients (e.g., post-surgery, stroke recovery) as a reminder of boundaries and for safety; typically, two or three rails are partly up for others to assist with repositioning, ensuring exits are clear.
Avoid using full side rails as a restraint if clients can safely exit with assistance or if it poses an entrapment risk; assess individual need.
Provide nonskid footwear (e.g., socks with treads, stable shoes) to improve traction and prevent slipping.
Keep floors clear of clutter (e.g., cords, personal belongings, spills) with a clear, unobstructed path to the bathroom.
Lock wheels on beds, wheelchairs, and carts to prevent rolling during transfers, ensuring stability and reducing risk of falls.
Use chair/bed sensors or pressure alarms to alert staff when clients at risk for independent ambulation attempt to get up unattended, allowing for prompt intervention.
Seizures
Seizures are uncontrolled electrical disturbances in the brain and can occur at any life stage. They may be due to epilepsy, high fever (febrile seizures), alcohol withdrawal, electrolyte imbalances, head injury, or other underlying neurological conditions.
SEIZURE PRECAUTIONS (for clients at risk of generalized tonic-clonic or unconscious seizures) include:
Assign a room near the nursing station for ease of observation and prompt response.
Insert a peripheral IV if needed for rapid administration of anti-seizure medications during an event.
Ensure rescue equipment is at the bedside, immediately accessible:
Oxygen: For administration during or after a seizure to prevent hypoxia.
Oral airway: To maintain a patent airway (inserted only AFTER the jaw is relaxed and during tonic-clonic phase, never forced).
Suction equipment: To clear secretions and prevent aspiration.
Instruct client and family on precautions when out of bed, such as not swimming alone or operating heavy machinery if risk of seizure is high.
Monitor during a seizure: Note onset time, duration, progression of activity, and post-ictal state. Protect client's head, loosen restrictive clothing, turn to side if possible to prevent aspiration, do not try to restrain movements or force anything into mouth.
Treat as indicated during a seizure: Administer prescribed anticonvulsant medications (e.g., benzodiazepines) as ordered upon onset of seizure activity. After the seizure, document thoroughly and perform a neurological assessment.
Note: Review Fundamentals chapter on Client Safety for deeper understanding; Safety and Infection Control constitute approximately 13 ext{ %} of NCLEX.
Seclusion and restraints
Used to prevent clients from injuring themselves or others (e.g., healthcare staff, other clients) when less restrictive interventions have failed and there is an imminent risk.
Seclusion: Placing a client alone in a safe, locked room with limited environmental stimuli, observed by staff.
Physical restraint: Any manual method, physical or mechanical device, material, or equipment thatimmobilizes or reduces the ability of a client to move his or her arms, legs, body, or head freely. Can constrain the whole body (e.g., four-point restraints) or a body part (e.g., wrist restraints).
Chemical restraints: Medications (e.g., sedatives, antipsychotics) used to control disruptive behavior or manage acute agitation for the convenience of staff or as a punishment, rather than for the client's direct safety or as part of their medical treatment plan.
Risks associated with restraints
Death by asphyxiation and strangulation: Particularly with improper application or use of certain types of restraints (e.g., some vest restraints are now largely prohibited due to this risk).
Complications related to immobility:
Pressure injuries (bedsores) due to prolonged pressure on bony prominences.
Urinary retention or fecal incontinence from inability to access bathroom.
Pneumonia (specifically aspiration pneumonia) due to decreased mobility and potential for aspiration.
Deep vein thrombosis (DVT) and pulmonary embolism (PE) due to venous stasis.
Nerve damage or circulatory impairment from too-tight application.
Psychological harm: increased agitation, fear, humiliation, social isolation, and decreased self-esteem.
Legal considerations of using restraints and seclusion
Nurses must understand and strictly adhere to agency policies, federal regulations (e.g., Medicare/Medicaid Conditions of Participation), and state laws regarding the use of restraints and seclusion.
False imprisonment: Unlawful confinement of a person without justification. Improper or unnecessary use of restraints can lead to charges of false imprisonment, assault, or battery against the healthcare provider and facility.
Restraint and seclusion guidelines
Use restraints only with a provider order and for the shortest time possible; attempt early release if the client's behavior indicates improvement and calmness.
Restraints are for protection and safety after all other less-restrictive methods of behavior change (e.g., verbal de-escalation, reorientation, diversion, frequent observation, medication review) have been attempted and documented as ineffective.
Explain the reason for restraint use to the client and family, emphasizing its temporary nature and the goal of ensuring safety.
PRN (as needed) prescriptions for restraints are never permitted; each application requires a new order.
The initial treatment must be prescribed by a provider (physician or other licensed independent practitioner) after a face-to-face assessment of the client.
Emergency exception: If immediate risk exists (e.g., client is violent and poses an imminent threat to self or others), the nurse can place restraints; a provider prescription must be obtained as soon as possible per policy (usually within 1 ext{ hour} for non-psychiatric settings). The provider must then perform a face-to-face assessment within a specified time frame (e.g., 4 ext{ hours} for adults in psychiatric settings).
The prescription must be specific and include:
REASON: The specific behavior necessitating restraint (e.g., "client attempting to pull out IV, combative").
TYPE: The specific type of restraint (e.g., "wrist restraints, 2 ext{-point}).
LOCATION: Where the restraints are to be applied (e.g., "bilateral upper extremities").
DURATION: The maximum time the restraint can be applied before a new order is needed.
BEHAVIORAL INDICATORS: Specific behaviors that warrant continued or discontinued restraint use.
In medical/surgical facilities, typical maximum prescription durations are:
8 ext{ hours} for adults.
2 ext{ hours} for ages 9 ext{ –}17.
1 ext{ hour} for under 9.
For violent/self-destructive adults in psychiatric settings, the initial order can be up to 4 ext{ hours}, and then re-evaluated.
Ongoing assessments and documentation:
Every 15 ext{-}30 ext{ minutes}: Assess circulation, sensation, and movement (CSM) of restrained extremities. Check skin integrity under restraints. Offer toileting, nutrition, hydration.
Every 2 ext{ hours} (or per policy): Release restraints for brief periods (one at a time) to allow for range of motion exercises and skin care, if client condition allows.
Continuous documentation: Behavior that necessitated restraint, less restrictive measures attempted, client's response, assessment findings, and care provided.
Fire safety
Fires in medical facilities are usually due to electrical issues (e.g., faulty equipment, frayed cords) or anesthetic equipment (e.g., open flames near oxygen or flammable gases). Smoking near oxygen sources is a particularly high risk.
All staff must know: locations of exits, fire alarms, fire extinguishers, and oxygen shut-off valves throughout the unit and facility.
Ensure equipment does not block fire doors, hallways, or emergency exits to maintain clear escape routes.
Know the unit and facility evacuation plan, including primary and secondary routes, and designated assembly areas. Participate in regular fire drills.
RACE protocol (a sequential action plan for fire emergencies):
RESCUE: Move clients who are in immediate danger away from the fire to a safer area; ambulatory clients can walk, while others may require assistance or bed/stretcher transport. Prioritize those closest to the fire first.
ALARM: Activate the fire alarm system (pull station) and immediately report details of the fire (exact location, type of fire) to the facility's designated emergency number or operator. This alerts the fire department and facility staff.
CONFINE: Close doors and windows in the fire area and adjacent areas to contain smoke and fire. Turn off oxygen and electrical devices in the affected zone. For life-support patients, continue to ventilate manually with a Bag-Valve-Mask (BVM) as you move them from the hazardous area.
EXTINGUISH: Use a fire extinguisher if the fire is small, contained, and you are trained and confident to do so. Otherwise, evacuate.
Fire extinguishers (PASS sequence) and classifications
PASS (an acronym for operating a fire extinguisher):
PULL the pin located at the top of the extinguisher, breaking the tamper seal.
AIM the nozzle at the base of the fire, not the flames. Extinguisher agents work by disrupting the fuel source.
SQUEEZE the handle to release the extinguishing agent.
SWEEP the nozzle from side to side, covering the area of the fire, until the fire is out.
Classifications of fire extinguishers:
Class A: For fires involving ordinary combustible materials such as paper, wood, fabric, rubber, and trash. These extinguishers typically use water or foam.
Class B: For fires involving flammable liquids and gases like oil, grease, gasoline, and paints. These extinguishers typically use carbon dioxide or dry chemical agents to smother the fire.
Class C: For fires involving energized electrical equipment. These extinguishers use non-conductive agents (e.g., carbon dioxide, dry chemical) to prevent electrical shock.
Class ABC extinguishers: Are multipurpose and can be used on Class A, B, and C fires.
Home safety
Nurses collaborate with the client, family, and interprofessional team (e.g., occupational therapy, social work) to promote client safety in the home environment, which is unique to each individual.
A home hazard evaluation should be conducted if risk factors for injury are present (e.g., upon discharge from hospital, for older adults living alone, for families with young children).
Risk factors include:
Age: Developmental stage impacts typical hazards (e.g., toddlers crawling, adolescents driving).
Mobility/balance: Impaired gait, muscle weakness, or dizziness increase risk of falls.
Safety knowledge: Lack of awareness about common household hazards or proper use of equipment.
Sensory/cognitive awareness: Impaired vision, hearing, memory deficits, or confusion reduce ability to detect or respond to dangers.
Communication: Language barriers or impaired speech can hinder communication of needs or hazards.
Home/work environment: Presence of physical hazards (clutter, poor lighting, stairs, unsafe chemicals), lack of smoke detectors, or occupational risks.
Community: Access to safe walkways, crime rates, exposure to environmental toxins.
Medical/pharmacological status: Chronic diseases, polypharmacy, or side effects of medications (e.g., drowsiness, orthostatic hypotension) can increase vulnerability.
Safety risks based on age and development status
Infants and toddlers: High injury risk due to their developmental stage, characterized by rapid physical growth, increasing mobility (e.g., crawling, walking), oral exploration (mouthing objects), and limited understanding of cause and effect or danger.
Preschool/school-age: Injury risk due to underdeveloped motor coordination, increasing independence, curiosity, and participation in unmonitored play.
Adolescents: Risk due to desire for independence, peer influence, risk-taking behaviors, and developing judgment.
Review Fundamentals for age-specific safety recommendations: Each developmental stage has unique safety considerations that require tailored interventions.
Safety risks – Infants and toddlers (select hazards)
Aspiration: Small objects (e.g., buttons, coins, small toys) are choking hazards; keep out of reach. Cut foods (e.g., hot dogs, grapes, nuts) into small, manageable pieces. Avoid supine feeding or bottle propping, which increases risk of aspiration and ear infections.
Water safety: Never leave infants or toddlers unattended in the bath, even for a moment. Block access to swimming pools with appropriate fencing and gates. Begin teaching water safety when developmentally appropriate (e.g., swimming lessons after age 1).
Suffocation: Ensure a safe sleep environment: place infants on their backs on a firm sleep surface without loose bedding, bumper pads, or soft objects. Avoid latex balloons and plastic bags around infants/toddlers. Teach CPR and Heimlich maneuver to caregivers.
Poisoning: Lock away all chemicals (e.g., cleaning products, pesticides, automotive fluids), medications (prescription and over-the-counter), and potential sources of lead (e.g., old paint, contaminated water in older homes). Use child-resistant containers. Keep poison control number accessible.
Falls: Prevent falls from cribs (lower mattress as child grows), high-changing surfaces (never leave unattended), stairs (use safety gates at top and bottom), and windows (install window guards or locks). Discontinue use of car seats or other restraints when child exceeds manufacturer weight/height limits. Use manufacturer guidelines for all child safety restraints (e.g., car seats, high chairs).
Motor vehicle injury: Follow car seat guidelines rigorously based on height/weight/age for proper installation and use (e.g., rear-facing as long as possible, then forward-facing with harness, then booster seat). Always use the back seat for children.
Burns: Monitor faucet temperatures to prevent scalding; ideally, set hot water heater to 120^ ext{F} (49^ ext{C}). Supervise use of hot items (e.g., beverages, stove). Use back burners, turn pot handles inward.
Keep matches, lighters, and electrical equipment (e.g., outlets, cords) out of reach or utilize safety covers/locks.
Safety risks – Preschool and school-age
DROWNING: Ensure children learn to swim and reinforce water safety rules (e.g., no running near pools). Always supervise children around pools, lakes, and oceans. Insist on life jackets when in boats or engaging in water sports.
MOTOR VEHICLE INJURY: Ensure proper car seat or booster seat use and placement until child is large enough for adult seat belt (typically 4 ext{ feet } 9 ext{ inches} tall and between 8 ext{ –}12 ext{ years} old). Emphasize seat belt use for all passengers. Promote and ensure use of appropriate protective sports gear (helmets, pads) for activities like biking, skateboarding, and team sports.
FIREARMS: Keep firearms unloaded, locked in a secure cabinet or safe, and entirely out of reach of children. Store bullets separately from the gun. Teach children never to touch a gun and to immediately tell an adult if they see one.
PLAY INJURY: Provide age-appropriate play equipment that meets safety standards. Teach children to avoid hazardous areas (e.g., construction sites, abandoned buildings) and machinery. Supervise children, especially around strangers, and teach them about "stranger awareness" and not to go with unknown individuals.
BURNS: Teach safe use of heating devices (e.g., space heaters – warn about keeping combustibles away) and hot surfaces (e.g., stoves, fireplaces). Emphasize fire escape routes and drills.
POISON: Educate children about the hazards of alcohol, cigarettes, illicit drugs, and medications. Keep all dangerous substances locked away and out of sight. Keep the poison control number accessible and teach children whom to call in an emergency.
Safety risks – Adolescents
MOTOR VEHICLE and injury risk: Leading cause of death and injury for this age group. Ensure driver’s education is completed. Set clear rules and limits on the number of passengers and driving hours (especially at night). Enforce consistent seat belt use for all occupants. Arrange safe rides if a driver is impaired by alcohol or drugs.
BURNS: Promote the use of sunblock and protective clothing when outdoors to prevent sunburns, which increase skin cancer risk. Warn about the dangers of tanning beds, which also increase skin cancer risk.
OTHER RISKS:
Monitor for signs of depression, anxiety, or other mental health issues; provide support and resources for mental well-being.
Educate on the dangers of smoking, vaping, substance use (alcohol, drugs), and unsafe sexual practices (e.g., STIs, unintended pregnancy); promote healthy choices.
Discuss risks of social networking and cyberbullying, emphasizing online safety, privacy settings, and appropriate digital citizenship.
Safety risks – Young and middle-age adults
MOTOR VEHICLE crashes: Remain the leading cause of death/injury in this age group, often linked to distracted driving, speeding, or impaired driving.
Occupational injuries: Contribute significantly to death/injury statistics due to work-related hazards (e.g., heavy machinery, chemicals, repetitive strain).
High alcohol use and suicide risk: These are concerning trends in this demographic.
CLIENT EDUCATION:
Follow recommended alcohol guidelines (1 ext{ drink/day} for women, 2 ext{ drinks/day} for men) and monitor for signs of dependence.
Monitor for depression or suicidal thoughts; educate on warning signs and encourage seeking professional help immediately.
Be aware of internet/network hazards (e.g., scams, identity theft, online predators) and maintain strong online security practices.
Protect skin with sun-block and protective clothing when exposed to UV light to prevent skin cancer.
Promote regular exercise, balanced nutrition, and stress management to maintain overall health and reduce risks.
Safety risks – Older adults
Prevention of injury is paramount due to longer recovery times, increased risk of complications (e.g., pneumonia, DVT), and higher mortality rates following injuries, especially falls.
FALL RISK factors: These are multifaceted and often compound each other.
Age-related changes: Vary widely among individuals but commonly include decreased bone density (osteoporosis), reduced muscle mass (sarcopenia), and delayed neurological reflexes.
Physical changes: Impaired balance, gait instability, generalized weakness.
Cognitive changes: Memory loss, confusion, dementia, which can lead to wandering or disoriented ambulation.
Sensory changes: Impaired vision (cataracts, macular degeneration), hearing loss (difficulty hearing warnings), decreased proprioception (sense of body position).
Musculoskeletal/Neurologic changes: Arthritis (pain, stiffness), Parkinson’s disease (gait disturbance), neuropathy (numbness, weakness).
Nocturia/incontinence: Frequent need to urinate at night, leading to hurried, unsupervised ambulation in dimly lit environments.
Medication side effects: Polypharmacy increases risk of adverse drug reactions like orthostatic hypotension, dizziness, and sedation.
HOME SAFETY modifications: Crucial for prevention.
Remove items that cause trips (e.g., throw rugs, clutter, loose cords).
Provide assistive devices (e.g., walkers, canes, grab bars in bathrooms, elevated toilet seats) and safety equipment tailored to individual needs.
Ensure adequate indoor/outdoor lighting, especially in hallways, stairs, and bathrooms, perhaps with nightlights or motion-sensor lights.
Install handrails on both sides of stairs.
Ensure flooring is nonskid and stable.
Home safety plan
Keep a clearly visible list of emergency numbers (e.g., fire, police, ambulance, poison control, family contacts) near all phones.
Develop and regularly practice a family evacuation plan for various emergencies (e.g., fire, natural disaster). Identify two escape routes from each room and a designated outside meeting place.
FIRE safety:
Ensure sufficient fire extinguishers (Class ABC) are easily accessible and maintained.
Install and regularly test smoke alarms and carbon monoxide detectors on every level of the home and inside each sleeping area (check batteries biannually).
Close windows/doors if possible when exiting a burning area to contain smoke and fire.
Escape a smoke-filled area by staying low to the floor (crawl under smoke) and using a damp cloth over nose and mouth to filter air.
If clothing catches fire, remember STOP, DROP, and ROLL (stop moving, drop to the ground, cover face, and roll over and over to smother flames).
Safe use of oxygen in the home
Oxygen supports combustion, increasing fire risk; teach clients and caregivers vital safety measures:
Use and store oxygen equipment per manufacturer’s instructions. Do not modify or tamper with equipment.
Post "NO SMOKING" signs prominently near the entrance door and in the client's bedroom/areas where oxygen is used. Ensure all smoking occurs outside the home, away from oxygen tanks.
Ensure all electrical equipment (e.g., blankets, razors, hair dryers) is well repaired, grounded, and in good working order to prevent sparks. Avoid using oil-based products (e.g., petroleum jelly) on or around the client's face, as they are flammable. Use water-based lubricants.
Use natural-fiber bedding (e.g., cotton) and clothing; avoid static-generating materials like wool, nylon, or synthetics, as static electricity can cause sparks.
Keep flammable materials (e.g., alcohol, paint thinners, aerosols, cleaning solutions) at least 10 ext{ feet} (3 ext{ meters}) away from oxygen cylinders and sources.
Follow general home fire safety measures, including having functional fire extinguishers and clear exits.
Additional risks / home and community
PASSIVE SMOKING (secondhand smoke): Inhaling smoke exhaled by smokers or from burning tobacco products. Increases risk for various cancers (lung, breast), heart disease, stroke, and chronic lung infections in adults. Has adverse effects on pregnancy outcomes (e.g., low birth weight, prematurity, stillbirth, Sudden Infant Death Syndrome (SIDS)). In children, it causes increased incidence of bronchitis, pneumonia, middle ear infections, and triggers/exacerbates asthma.
CARBON MONOXIDE (CO): Invisible, odorless, tasteless gas produced by incomplete combustion of fuel (e.g., gas furnaces, stoves, car exhaust, charcoal grills). It binds irreversibly to hemoglobin with an affinity 200 ext{ times} greater than oxygen, forming carboxyhemoglobin, thereby reducing oxygen delivery to tissues.
CO poisoning symptoms: Often flu-like and can be insidious, including nausea, vomiting, headache, dizziness, fatigue, and weakness. Severe poisoning leads to disorientation, unconsciousness, and death.
Action: If CO poisoning is suspected, immediately move to fresh air outdoors and seek Emergency Room care. Install CO detectors in the home, especially near sleeping areas. Ensure proper ventilation of fuel-burning appliances.
Additional risks / home and community (continued)
FOOD POISONING: Illness caused by consuming food contaminated with bacteria, viruses, parasites, or toxins. Commonly caused by bacteria (e.g., Escherichia coli (E. coli), Listeria monocytogenes, Salmonella, Campylobacter).
Highest risk groups: Very young children, very old adults, pregnant women, and immunocompromised individuals (e.g., those on chemotherapy, HIV/AIDS patients) due to underdeveloped or weakened immune systems.
Dietary considerations: Follow a low-microbial or neutropenic diet for high-risk individuals, meaning avoiding raw or undercooked foods and ensuring strict food safety.
MEASURES TO PREVENT FOOD POISONING:
Proper hand hygiene: Wash hands thoroughly with soap and water before and after handling food, especially raw meat, poultry, seafood, or eggs.
Cook to correct temperatures: Use a food thermometer to ensure eggs, meat, poultry, and fish are cooked to safe internal temperatures to kill pathogens.
Separate raw and cooked foods: Use separate cutting boards, plates, and utensils for raw and cooked foods to avoid cross-contamination.
Do not reuse containers/utensils: Never use the same container or utensil for raw meat/poultry/seafood and then for cooked food without washing it, or preparing raw fruits/vegetables.
Refrigerate perishable items promptly: Within 2 ext{ hours} (or 1 ext{ hour} if ambient temperature is above 90^ ext{F} (32^ ext{C})). Keep refrigerator temperature at or below 40^ ext{F} (4^ ext{C}).
Wash raw fruits/vegetables: Wash thoroughly under running water before cutting, peeling, or eating.
Avoid unpasteurized products: Do not consume unpasteurized dairy products (milk, cheese) or untreated water (e.g., from wells unless tested), as they can harbor harmful bacteria.
DISASTERS: Natural disasters (e.g., tornadoes, floods, earthquakes, hurricanes) and human-made events (e.g., chemical spills, forest fires, explosions, acts of terrorism) can occur without warning and necessitate rapid response.
Encourage personal and family emergency preparedness: Maintain an emergency supply kit (often called a "go bag" or "to-go kit") with non-perishable food (3 ext{-day} supply), water (1 ext{ gallon} per person per day for 3 ext{ days}), clothing, a battery-powered radio, communication device (charged cell phone, power bank), necessary medications, important documents (copies of ID, insurance), first-aid supplies, and cash. Develop a family communication plan.
Ergonomic principles and body mechanics
Ergonomics: The science of designing and arranging workplace tools, equipment, and environments to fit the worker effectively, contributing to comfort, safety, efficiency, and ease of use. Aims to minimize strain and injury.
BODY MECHANICS: The proper use of muscles to maintain balance, posture, and body alignment during daily activities and demanding tasks like lifting, transferring, or repositioning clients. This minimizes stress on the musculoskeletal system.
Nurses should consistently use proper body mechanics to prevent debilitating injuries (e.g., back strain, shoulder injuries), which are common in healthcare. Mechanical lift devices (e.g., Hoyer lift, stand-assist lift) should be used whenever possible for transfers and repositioning to reduce physical strain on staff and increase client safety. Many facilities enforce "no manual lift" and "no solo lift" policies to protect staff.
Guidelines to prevent injury
Know and follow facility policies regarding safe client handling and equipment use.
Plan ahead for lifting, transferring, or ambulating clients. Assess the client's ability to assist. Ask for assistance from other staff when needed, especially for heavy or uncooperative clients.
Maintain good posture: Keep the spine in a neutral alignment (ears over shoulders, shoulders over hips) and engage core muscles. Exercise regularly to strengthen legs, arms, back, and abdomen, which are key for stable lifting and movement.
Use smooth, controlled movements when lifting/moving clients; avoid sudden jerking motions.
When standing for long periods, flex hips and knees slightly, and use a foot rest or shift weight periodically to relieve pressure and maintain circulation. When seated for long periods, keep knees slightly higher than hips (e.g., by using a footstool under the feet) to promote correct lumbar curve.
Avoid repetitive hand/wrist/shoulder movements; take frequent short breaks (every 15 ext{ –}20 ext{ minutes}) to stretch and change positions.
Maintain good posture (head/neck aligned with pelvis) even during static tasks (e.g., documentation at a computer). Avoid neck flexion (looking down for extended periods) and slouched shoulders.
Avoid twisting the spine or bending at the waist when hips/knees are not bent; bending at the knees and hips (squatting) minimizes injury risk by engaging leg muscles rather than straining the back.
Keep objects (or clients) close to the body’s center of gravity when lifting/moving. This reduces the leverage required and minimizes strain. Bend knees to lift, rather than using the back.
When lifting from the floor: flex hips/knees/back (squat down), bring object to thigh level, keep it close to body, and stand up by straightening legs, using leg muscles.
Face the direction of movement when moving a client (e.g., when pulling or pushing a stretcher) to avoid twisting the spine.
Sliding/rolling/pushing (e.g., using a slide board or friction-reducing device) uses significantly less energy and reduces injury risk compared to lifting.
Avoid twisting the thoracic spine (upper back) and bending the back while hips/knees are straight, as this places excessive stress on the lumbar spine.
Assess client’s ability to assist with repositioning/mobility (e.g., balance, strength, endurance, comprehension of instructions).
Determine the need for additional personnel or assistive devices (e.g., transfer belt/gait belt for ambulation assistance, hydraulic lift for full body transfers, sliding board for lateral transfers from bed to stretcher) based on client assessment and task requirements.