Patient Safety

Oxygen: Supplemental oxygen is sometimes required to meet a person’s oxygenation needs. Oxygen is not flammable, but fire needs oxygen to start and to keep burning. When more oxygen is in the air, a fire burns hotter and faster. Strict codes regulate the use and storage of medical oxygen in health care facilities. This is not necessarily true in the home environment. Hospital emergency departments see approximately 1190 thermal burns per year caused by ignitions associated with home medical oxygen (National Fire Protection Association, 2008). Smoking is by far the leading cause of burns, reported fires, deaths, and injuries involving home medical oxygen.

Be aware of factors in a patient’s environment that decrease the amount of available oxygen. A common environmental hazard in the home is an improperly functioning heating system. A furnace, stove, or fireplace that is not properly vented introduces carbon monoxide into the environment. Carbon monoxide affects a person’s oxygenation by binding with hemoglobin, preventing the formation of oxyhemoglobin and thus reducing the supply of oxygen delivered to tissues (see Chapter 40). Low concentrations cause nausea, dizziness, headache, and fatigue. Very high concentrations cause death after 1 to 3 minutes of exposure (National Fire Protection Association, 2010a).

Nutrition: Meeting nutritional needs adequately and safely requires environmental controls and knowledge (see Chapter 44). Health care facilities and restaurants are required to meet State Board of Health regulations. To protect consumers, commercially processed and packaged foods are subject to Food and Drug Administration (FDA) regulations. The FDA is a federal agency responsible for the enforcement of federal regulations regarding the manufacture, processing, and distribution of foods, drugs, and cosmetics to protect consumers against the sale of impure or dangerous substances. Although food supply in the United States is one of the safest in the world, each year about 76 million illnesses occur, more than 300,000 persons are hospitalized, and 5,000 die from foodborne illness (Centers for Disease Control and Prevention, 2009). Groups at the highest risk are children, pregnant women, older adults, and people with compromised immune systems. Foods that are inadequately prepared or stored or subject to unsanitary conditions increase the patient’s risk for infections and food poisoning.

Temperature: A person’s comfort zone is usually between 18.3° and 23.9° C (65° and 75° F). Temperature extremes that frequently occur during the winter and summer affect comfort, productivity, and safety. Exposure to severe cold for prolonged periods causes frostbite and accidental hypothermia. Frostbite occurs when a surface area of the skin freezes as a result of exposure to extremely cold temperatures. Hypothermia occurs when the core body temperature is 35° C (95° F) or below. Older adults, the young, patients with cardiovascular conditions, patients who have ingested drugs or alcohol in excess, and people who are homeless are at high risk for hypothermia. Exposure to extreme heat changes the electrolyte balance of the body and raises the core body temperature, resulting in heatstroke or heat exhaustion. Chronically ill patients, older adults, and infants are at greatest risk for injury from extreme heat. These patients need to avoid extremely hot, humid environments (see Chapter 29).

Motor Vehicle Accidents: Vehicle design and equipment such as seat belts, air bags, and laminated windshields (remain in one piece when impacted) have improved safety for vehicle occupants. State specific laws relating to young driver licensing, safety belt use, child restraint use, and motorcycle helmets exist for protection. Child safety seats and booster seats appropriate for the child’s age and weight and the type of car need to be used (Fig. 27-1). The American Academy of Pediatrics (2011) recommends that all infants and toddlers ride in the back seat with a rear-facing car safety seat until they are 2 years of age or they reach the highest weight or height allowed by the manufacturer of the car safety seat. The website of the Academy, Healthy Children, http://www.aap.org/healthtopics/carseatsafety.cfm, has information for children of all ages and the type of safety seat to use. The back seat of a car is the safest part of the vehicle in the event of a crash and prevents injury from deployment of passenger and side air bags. According to the Centers for Disease Control and Prevention (2010b), the risk of motor vehicle accidents is higher among 16- to 19-year-old drivers than any other age-group. Teens are more likely to underestimate dangerous situations or not be able to recognize hazardous situations, speed and allow shorter headways, ride with intoxicated drivers, and drive after using alcohol and drugs. Teens also have the lowest rate of seat belt use. Older drivers are keeping their licenses longer and driving more miles than in the past. Per mile traveled, fatal crash rates increase starting at age 75 and increase markedly after age 80 (Insurance Institute for Highway Safety, 2008). An older adult is not always able to quickly observe situations in which an accident is likely to occur. Decreased hearing acuity alters the ability to hear emergency vehicle sirens or vehicle horns. Because of decreased nervous system response, older adults are unable to react as quickly as they once could to avoid an accident. A decline in these skills accounts for the most common types of accidents, including right-of-way and turning accidents.

Poison: A poison is any substance that impairs health or destroys life when ingested, inhaled, or absorbed by the body. Almost any substance is poisonous if too much is taken. Sources in a person’s home include drugs, medicines, other solid and liquid substances, and gases and vapors. Poisons often impair the function of every major organ system. Health care providers are at risk from chemicals such as toxic cleaning agents. In the home accidental poisoning is a greater risk for toddlers, preschoolers, and young school-age children, who often ingest household cleaning solutions, medications, or personal hygiene products. Emergency treatment is necessary when a person ingests a poisonous substance or comes in contact with a chemical that is absorbed through the skin. In 2008 more than 2000 people a day were seen in emergency departments after a poison incident (Centers for Disease Control and Prevention, 2010c). Specific antidotes or treatments are available only for some types of poisons. A poison control center is the best resource for patients and parents needing information about the treatment of an accidental poisoning.

Although lead has not been used in house paint or plumbing materials since the U.S. Consumer Product Safety Commission banned it in 1978, older homes in poorer communities continue to contain high lead levels. Soil and water systems are sometimes contaminated. Poisoning occurs from swallowing or inhaling lead. Fetuses, infants, and children are more vulnerable to lead poisoning than adults because their bodies absorb lead more easily and small children are more sensitive to the damaging effects of lead. Exposure to excessive levels of lead affects a child’s growth or causes learning and behavioral problems and brain and kidney damage (Agency for Toxic Substances and Disease Registry, 2010).

Falls: Falls are a major public health problem. Among adults 64 years and older, falls are the leading cause of unintentional death (Centers for Disease Control and Prevention, 2010a). Numerous factors increase the risk of falls, including a history of falling, being age 65 or over, reduced vision, orthostatic hypotension, gait and balance problems, urinary incontinence, use of walking aids, and the effects of various medications (e.g., anticonvulsants, hypnotics, sedatives, certain analgesics) (Deandrea et al., 2010). Common physical hazards that lead to falls include inadequate lighting, barriers along normal walking paths and stairways, and a lack of safety devices in the home. Often a fall leads to serious injury such as fractures or internal bleeding. Patients most at risk for injury are those with bleeding tendencies resulting from disease or medical treatments and osteoporosis. Injuries frequently result from accidental contact with objects on stairs, floors, bedside tables, closet shelves, refrigerator tops, and bookshelves. Children fall from anywhere (i.e., trees, wall/fences, playground equipment, furniture, and moving objects such as skateboards and bicycles). Forces from falls lead to injury with variable severity, depending on the height of the fall, body position on impact, and impact surface.

Fire: A total of 386,500 home fires were reported in the United States in 2008, resulting in 2,755 deaths and 13,160 injuries (National Fire Protection Association, 2010b). The leading cause of fire-related death is careless smoking, especially when people smoke in bed at home. The improper use of cooking equipment and appliances, particularly stoves, is the main source for in-home fires and fire injuries. Smoke detectors and carbon monoxide detectors need to be placed strategically throughout a home. Multipurpose fire extinguishers need to be near the kitchen and any workshop areas.

Disasters: When they strike, natural disasters such as floods, tsunamis, hurricanes, tornadoes, and wildfires are a major cause of death and injury. These types of disasters result in death and leave many people homeless. Every year millions of Americans face disaster and its terrifying consequences (FEMA, 2010). Bioterrorism is another cause of disaster. Threats of this type come in the form of biological, chemical, and radiological attacks. Bioterrorism, or the use of biological agents to create fear and threat, is the most likely form of a terrorist attack to occur. Although terrorists could use any agent, health officials are most concerned with biological agents such as anthrax, smallpox, pneumonic plague, botulism, tularemia, and viral hemorrhagic fevers (American Medical Association, 2010).

Infant, Toddler, and Preschooler: Injuries are the leading cause of death in children over age 1 and cause more death and disabilities than do all diseases combined (Hockenberry and Wilson, 2009). The nature of the injury sustained is closely related to normal growth and development. For example, the incidence of lead poisoning is highest in late infancy and toddlerhood. Children at this stage explore the environment and, because of their increased level of oral activity, put objects in their mouth. This increases risk for poisoning and choking. Fire often results from their curiosity in playing with matches. In addition, limited physical coordination contributes to falls from bicycles and playground equipment. Additional injuries at this age are related to riding unrestrained in a motor vehicle, drowning, and head trauma from objects. Accidents involving children are largely preventable, but parents need to be aware of specific dangers at each stage of growth and development. Accident prevention thus requires health education for parents and the removal of dangers whenever possible.

School-Age Child: When a child enters school, the environment expands to include the school, transportation to and from school, school friends, and after-school activities. School-age children are learning how to perform more complicated motor activities and often are uncoordinated. Parents, teachers, and nurses need to instruct children in safe practices to follow at school or play, including what to do if approached by strangers. Teach school-age children involved in team and contact sports the rules for playing safely and how to use protective safety equipment such as helmets and other protective gear. Head injuries are a major cause of death, with bicycle accidents being one of the major causes of such injuries (Hockenberry and Wilson, 2009). Bikes need to be the proper size for the child, and helmets must be worn (Fig. 27-2). Additional injuries in this age-group are decreased by properly using seat belts and booster seats in motor vehicles and providing pedestrian safety education.

Adolescent: As children enter adolescence, they develop greater independence and begin to develop a sense of identity and their own values. The adolescent begins to separate emotionally from his or her family, and peers generally have a stronger influence. Wide variations that swing from childlike to mature behavior are characteristic of adolescent behavior (Hockenberry and Wilson, 2009). In an attempt to relieve the tensions associated with physical and psychosocial changes and peer pressures, some adolescents engage in risk-taking behaviors such as smoking, drinking alcohol, and using drugs. This increases the incidence of accidents such as drowning and motor vehicle accidents. When adolescents learn to drive, their environment expands, and so does their potential for injury. Fortunately teen motor vehicle crashes are preventable by avoiding distractions such as using cell phones, texting, eating, and drinking while driving.

To assess for possible substance abuse, have parents look for environmental and psychosocial clues from their children. Environmental clues include the presence of drug-oriented magazines, beer and liquor bottles, drug paraphernalia and blood spots on clothing and the continual wearing of long-sleeved shirts in hot weather and dark glasses indoors. Psychosocial clues include failing grades, change in dress, increased absenteeism from school, isolation, increased aggressiveness, and changes in interpersonal relationships. Because adolescence is a time when mature sexual physical characteristics develop, some adolescents begin to have physical relationships with others that present the risk of sexually transmitted diseases.

Adult: The threats to an adult’s safety are frequently related to lifestyle habits. For example, a person who uses alcohol excessively is at greater risk for motor vehicle accidents. People who smoke long-term have a greater risk of cardiovascular or pulmonary disease as a result of the inhalation of smoke and the effect of nicotine on the circulatory system. Likewise, the adult experiencing a high level of stress is more likely to have an accident or illness such as headaches, gastrointestinal (GI) disorders, and infections.

Older Adult: The physiological changes associated with aging, effects of multiple medications, psychological factors, and acute or chronic disease increase the older adult’s risk for falls and other types of accidents. Falls often result in bruises, hip fractures, or head trauma. The risk of being seriously injured in a fall increases with age. Older patients are more likely to fall in the bedroom, bathroom, and kitchen. Environmental factors such as broken stairs, icy sidewalks, inadequate lighting, throw rugs, and exposed electrical cords cause many of the accidents. Inside falls most often occur while transferring from beds, chairs, and toilets; getting into or out of bathtubs; tripping over items such as cords covered by rugs or carpets, carpet edges, or doorway thresholds; slipping on wet surfaces; and descending stairs. Fear of falling is a concern of community-dwelling older adults, and many avoid activities because of their fear (Zijlstra et al., 2007). Falls can be decreased by multiple-component group exercise, Tai Chi, having a physician or pharmacist review all medications, having an eye examination annually, and decreasing hazards in the home that increase falls (Gillespie et al., 2009).

Lifestyle: Some lifestyle choices increase safety risks. People who drive or operate machinery while under the influence of chemical substances (drugs or alcohol), work at inherently dangerous jobs, or are risk takers are at greater risk of injury. In addition, people experiencing stress, anxiety, fatigue, or alcohol or drug withdrawal or those taking prescribed medications are sometimes more accident prone. Because of these factors, some people are too preoccupied to notice the source of potential accidents such as cluttered stairs or a stop sign.

Impaired Mobility: A patient with impaired mobility has many kinds of safety risks. Muscle weakness, paralysis, and poor coordination or balance are major factors in falls. Immobilization predisposes patients to additional physiological and emotional hazards, which in turn further restrict mobility and independence. Persons who are physically challenged are at greater risk for injury when entering motor vehicles and buildings that are not handicapped accessible.

Sensory or Communication Impairment: Cognitive impairments associated with delirium, dementia, and depression place patients at greater risk for injury. These conditions contribute to altered concentration and attention span, impaired memory, and orientation changes. Patients with these alterations become easily confused about their surroundings and are more likely to have falls and burns. Patients with visual, hearing, tactile, or communication impairment such as aphasia or a language barrier are not always able to perceive a potential danger or express their need for assistance (see Chapter 49).

Lack of Safety Awareness: Some patients are unaware of safety precautions such as keeping medicine or poisons away from children or reading the expiration date on food products. A complete nursing assessment, including a home inspection, helps you identify the patient’s level of knowledge regarding home safety so you can correct deficiencies with an individualized nursing care plan.

• Building consensus on national priorities and goals for performance improvement and working in partnership to achieve them;

• Endorsing national consensus standards for measuring and publicly reporting on performance; and

• Promoting the attainment of national goals through education and outreach programs.

Falls: Falls result in minor to severe injuries such as hip fractures or head trauma that result in reduced mobility and independence and increase the risk for premature death. Patients who have underlying disease states are more susceptible to fall-related injuries (Hughes, 2008). For example, a patient with a bleeding disorder is more likely to have an intracranial bleed; a patient with osteoporosis has a greater chance for fracture. The unfamiliar environment, acute illness, surgery, mobility status, medications, treatments, and placement of various tubes and catheters are common challenges that place patients of any age at risk of falling. Factors the nurse can influence include assessment and communication about patient risks, information access, signage, the environment, teamwork, and involving the patient and family (Dykes et al., 2009). Falls that result in injuries often extend a patient’s length of stay in the health care environment, placing them at an even greater risk for other complications.

Patient-Inherent Accidents: Patient-inherent accidents are accidents (other than falls) in which the patient is the primary reason for the accident. Examples include self-inflicted cuts, injuries, and burns; ingestion or injection of foreign substances; self-mutilation or fire setting; and pinching fingers in drawers or doors. One of the more common precipitating factors for a patient-inherent accident is a seizure.

Procedure-Related Accidents: Procedure-related accidents are caused by health care providers and include medication and fluid administration errors, improper application of external devices, and accidents related to improper performance of procedures such as dressing changes or urinary catheter insertion. Nurses are able to prevent many procedure-related accidents by adhering to organizational policy and procedures and standards of nursing practice. For example, proper preparation and administration of medications, use of patient and medication bar coding, and “Smart” intravenous (IV) pumps reduce medication errors (see Chapters 31 and 41). All staff need to be aware that distractions and interruptions contribute to procedure-related accidents and need to be limited, especially during high-risk procedures such as medication administration. The potential for infection is reduced when surgical asepsis is used for sterile dressing changes or any invasive procedure such as insertion of a urinary catheter. Finally, correct use of safe patient handling techniques and equipment reduces the risk of injuries when moving and lifting patients (see Chapter 47).

Equipment-Related Accidents: Accidents that are equipment related result from the malfunction, disrepair, or misuse of equipment or from an electrical hazard. To avoid rapid infusion of IV fluids, all general-use and patient-controlled analgesic pumps need to have free-flow protection devices. To avoid accidents, do not operate monitoring or therapy equipment without adequate instruction. If faulty equipment is discovered, place a tag on it to prevent it from being used on another patient and promptly report any malfunctions. Assess potential electrical hazards to reduce the risk of electrical fires, electrocution, or injury from faulty equipment. In health care settings the clinical engineering staff make regular safety checks of equipment. Facilities must report all suspected medical device—related deaths to both the FDA and the manufacturer of the product if known (FDA, 2009). This is usually done in conjunction with the risk management department after tagging and removing the piece of equipment.

Risk for Falls: Assessment of a patient’s risk factors for falling is essential in determining specific needs and developing targeted interventions to prevent falls. Many different fall assessment instruments are available; use the tool chosen by your health care agency. A fall assessment tool (Table 27-1) helps you assess important risk factors. At a minimum the assessment needs to be completed on admission, following a change in the patient’s condition, after a fall, and when transferred. If it is determined that the patient is at risk for falling, regular assessment always continues. In many cases family members are important resources in assessing a patient’s fall risk. Families often are able to report on the patient’s level of confusion and ability to ambulate. Based on the results of a fall risk assessment, you implement multiple evidence-based interventions. It is very important to inform a patient and family members about the patient’s risks. Often younger patients are not aware of how medications and treatments cause dizziness, orthostatic hypotension, or changes in balance. When patients are unaware of their risks, they are less likely to ask for assistance. If family members are informed, they will often call for help (when they are visiting patients) to be sure that patients are appropriately assisted.

Risk for Medical Errors: Be alert to factors within your own work environment that create conditions in which medical errors are more likely to occur. Studies show that overwork and fatigue cause a significant decrease in alertness and concentration, leading to errors (Trinkoff et al., 2006). It is important for you to be aware of these factors and include checks and balances when working under stress. For example, to reduce the potential for a medical error, it is essential for you to check the patient’s identification by using two identifiers (e.g., name and birthday or name and account number) according to facility policy before beginning any procedure or administering a medication (see Chapter 31).

Disasters: Hospitals must be prepared to respond and care for a sudden influx of patients at the time of a community disaster. Guidelines for a disaster response are included in a facility emergency management plan. All hospitals conduct disaster drills on a routine basis. Communication is a key to any emergency management plan. Nurses must know what happened, how many patients to expect, and when patients will begin to arrive so they can prepare both themselves and their facility. Although the occurrence of a bioterrorist attack has been limited to the anthrax deaths following September 11, 2001, the threat is very real. Be prepared to make accurate and timely assessments in any type of setting. A bioterrorist attack will likely resemble a natural outbreak initially. Acutely ill patients representing the earliest cases after a covert attack seek care in emergency departments. Patients less ill at the onset of an illness possibly seek care in primary care settings. Basic epidemiological principles exist to assess whether a patient’s presentation of symptoms is typical of an endemic disease or an unusual event that raises concern. Features that alert nurses to the possibility of a bioterrorism-related outbreak include the following (Dire, 2008):

• Patient uses tripod cane correctly within 24 hours.

• Patient describes approach to rise up from bed correctly with assistance by end of the teaching session today.

Developmental Interventions:

Environmental Interventions: Nursing interventions directed at eliminating environmental threats include those associated with a person’s basic needs and general preventive measures.

Falls: Most hospitals have fall prevention protocols instituted for patients at risk for falling. For example, a patient receives a fall risk identification bracelet (yellow in color), is given information about fall risks, and receives additional nursing interventions (e.g., hourly rounding, placement on a low safety bed, yellow gown). Include family members in safety discussions. A gait belt provides a secure way to steady or guide patients who need assistance with ambulation when transferring or walking. Use additional safety equipment as needed when moving patients (see Chapter 47). When patients use assistive aids such as canes, crutches, or walkers, it is important to routinely check the condition of rubber tips and the integrity of the aid. Remove excess furniture and equipment and make sure that patients wear rubber-soled shoes or slippers for walking or transferring. Safety bars near toilets (Fig. 27-7), locks on beds and wheelchairs (Fig. 27-8), and call lights are additional safety features found in health care settings. In the health care environment frequent observations of the patient at risk for falls are important to reduce the potential for injury (Meade et al., 2006).

Restraints: Patients who are confused, disoriented, or repeatedly fall or try to remove medical devices (e.g., oxygen equipment, IV lines, or dressings) often require the temporary use of restraints to keep them safe. Restraints are not a solution to a patient problem but rather a temporary means to maintain patient safety. They are either chemical or physical. Chemical restraints are medications such as anxiolytics and sedatives used to manage a patient’s behavior and are not a standard treatment or dosage for the patient’s condition. A physical restraint is any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely (TJC, 2011a). A restraint does not include devices such as orthopedically prescribed devices, surgical dressings or bandages, protective helmets, or other methods that involve physically holding a patient to conduct routine physical examinations or tests, protecting the patient from falling out of bed, or permitting the patient to participate in activities without the risk of physical harm (TJC, 2011a).

The use of restraints is associated with serious complications resulting from immobilization such as pressure ulcers, pneumonia, constipation, and incontinence. In some cases death has resulted because of restricted breathing and circulation. Patients have been strangled while trying to get out of bed while restrained in a jacket or vest restraint. As a result, many health care facilities have eliminated the use of the jacket (vest) restraint (Capezuti et al., 2008). Loss of self-esteem, humiliation, and agitation are also serious concerns. Because of these risks, legislation emphasizes reducing the use of restraints. Regulatory agencies such as TJC and the CMS enforce standards for the safe use of restraint devices. The optimal goal for all patients is a restraint-free environment. Always consider and implement alternatives to restraints first. Individualize your approaches for each patient. Restraint alternatives include more frequent observations, involvement of family during visitation, frequent reorientation, and the introduction of familiar and meaningful stimuli (e.g., knitting or crocheting or looking at family photos) within the environment to reduce behaviors such as wandering that often leads to restraint use (Box 27-13).

In nursing homes, evidence shows that outcomes related to behavior issues, cognitive performance, falls, walking dependence, activities of daily living, pressure ulcers, and contractures are significantly worse when a restraint is used compared to no restraint (Castle, 2009). An interdisciplinary approach that includes individualized assessments and development of structured treatment plans reduces restraint use.

The use of restraints involves a psychological adjustment for the patient and family. If restraints are necessary, the nurse assists family members and patients by explaining their purpose, expected care while the patient is restrained, precautions taken to avoid injury, and that the restraint is temporary and protective. Informed consent from family members is sometimes required before using restraints (e.g., in long-term care settings).

For legal purposes know agency-specific policy and procedures for appropriate use and monitoring of restraints. The use of a restraint must be clinically justified and a part of the patient’s prescribed medical treatment and plan of care. A physician’s order is required, based on a face-to-face assessment of the patient. The order must be current, state the type and location of restraint, and specify the duration and circumstances under which it will be used. These orders need to be renewed within a specific time frame according to the policy of the agency. In the hospital each original restraint order and renewal is limited to 4 hours for adults, 2 hours for ages 9 through 17, and 1 hour for children under age 9 (CMS, 2009; TJC, 2011a). Orders may be renewed to the time limits for a maximum of 24 consecutive hours. Restraints are not to be ordered prn (as needed). You must conduct ongoing assessment of patients who are restrained. Proper documentation, including the behaviors that necessitated the application of restraints, the procedure used in restraining, the condition of the body part restrained (e.g., circulation to hand), and the evaluation of the patient response, is essential. Restraints must be removed periodically, and the nurse assesses the patient to determine if they continue to be necessary. Skill 27-1 on pp. 388-392 includes guidelines for the proper use and application of restraints. Use of restraints must meet one of the following objectives:

In keeping with current safety trends, electronic devices are also sometimes used as alternatives to restraints. For example, the Ambularm, worn on the leg, signals when the leg is in a dependent position such as over the side rail or on the floor (Fig. 27-9). You also sometimes place weight-sensitive sensor mats on patients’ mattresses or in the chair. An audible alarm sounds at the bedside when pressure is released off the sensor mat. The alarm often signals at the central nurses’ station so staff is alerted quickly when a patient is up and out of bed. Alarms on doors also alert staff or family members when a patient who is confused, disoriented, or prone to wandering opens a door.

A less-restrictive restraint is the Posey bed (Fig. 27-10). It is a soft-sided, self-contained enclosed bed that is much less restrictive than chemical or physical restraints. It allows for freedom of movement and thus reduces the side effects such as pressure ulcers and loss of dignity caused by physical restraints. A vinyl top covers the padded upper frame of the bed, and the nylon-net canopy surrounds the mattress and completely encloses the patient in the bed. Zippers on the four sides of the enclosure provide access to the patient. The Posey bed enclosure works well for patients who are restless and unpredictable, cognitively impaired, and at risk for injury if they were to fall or get out of bed such as patients on anticoagulant therapy at risk for intracranial bleed. The bed is also a safer alternative to side rails.

Side Rails: Side rails help to increase a patient’s mobility and/or stability when in bed or moving from bed to chair. They are the most commonly used physical restraint. There are a variety of beds with different side rail designs. Basically the patient needs to have a route to exit a bed safely and maneuver freely within the bed; in this case side rails are not considered a restraint. For example, raising only the top two side rails so the lower part of the bed is open gives the patient room to exit a bed safely. Side rails used to prevent a patient such as one who is sedated from falling out of bed are not considered a restraint. Always check agency policy about the use of side rails. Be sure that a bed is in the lowest position possible when side rails are raised. Always assess the risk of using side rails compared to not using them. Check their condition; bars between the bed rails need to be closely spaced to prevent entrapment, the space between bed rails and mattress and between headboard and mattress is filled to prevent patients from falling in between, and latches securing bed rails are stable.

The use of side rails alone for a patient who is disoriented usually causes more confusion and further injury. A patient who is determined to get out of bed attempts to climb over the side rail or climbs out at the foot of the bed. Either attempt usually results in a fall or injury. Nursing interventions to reduce a patient’s confusion first focus on determining and eliminating the cause of the confusion such as a response to a new medication, dehydration, or pain. Frequently nurses mistake a patient’s attempt to explore his or her environment or to self-toilet as confusion. Additional safety measures include the use of a low bed with a nonskid mat placed alongside the bed on the floor. A low bed reduces the distance between the bed and floor, facilitating a roll rather than a fall from the bed.

Fires: Although smoking is usually not allowed in hospital settings, smoking-related fires continue to pose a significant risk because of unauthorized smoking in the bed or bathroom. Institutional fires typically result from an electrical or anesthetic-related fire. The best intervention is to prevent fires. Nursing measures include complying with the smoking policies of the agency and keeping combustible materials away from heat sources. Box 27-14 discusses additional fire intervention guidelines for nurses in health care agencies. Regardless of where a fire occurs, it is important to have an evacuation plan in place. Know where fire extinguishers and gas shut-off valves are located and how to activate a fire alarm.

If a fire occurs in a health care agency, protect patients from immediate injury, report the exact location of the fire, contain it, and extinguish it if possible. Some agencies have fire doors that are held open by magnets and close automatically when a fire alarm sounds. It is important to keep equipment away from blocking these doors. All personnel evacuate patients when appropriate. Patients who are close to the fire, regardless of its size, are at risk of injury and need to be moved to another area. If the patient is on life support, you need to maintain his or her respiratory status manually with a bag-valve-mask device (e.g., Ambu-bag) (see Chapter 40) until he or she is moved away from the fire. Direct all ambulatory patients to walk by themselves to a safe area. In some cases they are able to help move patients in wheelchairs. You generally move bedridden patients from the scene of a fire by a stretcher, their bed, or a wheelchair. If none of these methods is appropriate, they need to be carried from the area. If you have to carry a patient, do so correctly (e.g., two-man carry). If you overextend your physical limits for lifting, injuring yourself results in further injury to the patient. If fire department personnel are on the scene, they help evacuate the patients.

After a fire is reported and patients are out of danger, nurses and other personnel take measures to contain or extinguish it such as closing doors and windows, placing wet towels along the base of doors, turning off sources of oxygen and electrical equipment, and using a fire extinguisher. Fire extinguishers are categorized as type A, used for ordinary combustibles (e.g., wood, cloth, paper, and many plastic items); type B, used for flammable liquids (e.g., gasoline, grease, paint, and anesthetic gas); and type C, used for electrical equipment. Fig. 27-11 demonstrates the process of using an extinguisher.

Electrical Hazards: Much of the equipment used in health care settings is electrical and must be well maintained. The clinical engineering departments of hospitals inspect biomedical equipment such as hospital beds, infusion pumps, or ventilators regularly. You know that a piece of equipment is safe to use when you see a safety inspection sticker with an expiration date. Decrease the risk for electrical injury and fire by using properly grounded and functional electrical equipment. The ground prong of an electrical outlet carries any stray electrical current back to the ground. Remove equipment that is not in proper working order or that sparks when plugged in for service and notify the appropriate hospital staff.

Seizures: Patients who have experienced some form of neurological injury or metabolic disturbance are at risk for a seizure. A seizure is hyperexcitation and disorderly discharge of neurons in the brain leading to a sudden, violent, involuntary series of muscle contractions that is paroxysmal and episodic, causing loss of consciousness, falling, tonicity (rigidity of muscles), and clonicity (jerking of muscles). A generalized tonic-clonic, or grand mal, seizure lasts approximately 2 minutes (no longer than 5) and is characterized by a cry and loss of consciousness with falling, tonicity, clonicity, and incontinence. During a fall or as a result of muscle jerking, musculoskeletal injuries can occur. Before a convulsive episode a few patients report an aura, which serves as a warning or sense that a seizure is about to occur. An aura is often a bright light, smell, or taste. During the seizure activity the patient often experiences shallow breathing, cyanosis, and loss of bladder and bowel control. A postictal phase follows the seizure, during which the patient has amnesia or confusion and falls into a deep sleep. A person in the community needs to be taken to a medical facility immediately if he or she has repeated seizures; if a single seizure lasts longer than 5 minutes without any sign of slowing down or is unusual in some way; if the person has trouble breathing afterwards or appears to be injured or in pain; or if recovery is different from usual (Epilepsy Foundation, 2010). Prolonged or repeated seizures indicate status epilepticus. This condition is a medical emergency and requires intensive monitoring and treatment. It is important that you observe the patient carefully before, during, and after the seizure so you are able to document the episode accurately. Seizure precautions encompass all nursing interventions to protect the patient from traumatic injury, position for adequate ventilation and drainage of oral secretions, and provide privacy and support following the seizure (see Skill 27-2 on pp. 392-294).

Radiation: Radiation is a health hazard in health care settings where radiation and radioactive materials are used in the diagnosis and treatment of patients. Hospitals have strict guidelines concerning the care of patients who are receiving radiation and radioactive materials. Be familiar with established agency protocols. To reduce your exposure to radiation, limit the time spent near the source, make the distance from the source as great as possible, and use shielding devices such as lead aprons. Staff regularly working near radiation wear devices that track the accumulative exposure to radiation.

Disasters: As a nurse, you need to be prepared to respond and care for a sudden influx of patients during a disaster. TJC (2011b) requires hospitals to have an emergency management plan that addresses identifying possible emergency situations and their probable impact, maintaining adequate amount of supplies, and a formal response plan that includes actions to be taken by staff and steps to restore essential services and resume normal operations following the emergency.

Infection control practices are critical in the event of a biological attack. Therefore you manage all patients with suspected or confirmed bioterrorism-related illnesses using standard precautions (see Chapter 28). For certain diseases such as smallpox or pneumonic plague, additional precautions such as airborne or contact isolation precautions are necessary. Most infections associated with biological agents are not transmissable from patient to patient. However, limit the transport and movement of patients to movement that is essential for treatment and care. An important aspect of care for patients who have a bioterrorism-related illness is postexposure management.

• What factors led to your fall?

• Help me understand what makes you feel unsafe in your environment.

• What questions do you have about your safety?

• Has your health care provider recently changed your medications?

• Do you need help locating community resources to help make your home safer?

• What changes have you recently experienced that you believe contributes to your risk for falling or lack of safety?

1. You know that a health care provider’s order is required for the restraint. What are essential components of the restraint order?

2. What assessments do you need to perform on Ms. Cohen while she is restrained?

3. The physician orders a belt restraint. Your assessment of Ms. Cohen the next day reveals that during the day she is alert and pleasantly confused but not attempting to get out of bed. Do you continue use of the restraint? Explain.

1. The nurse’s first action after discovering an electrical fire in a patient’s room is to:

2. A parent calls the pediatrician’s office frantic about the bottle of cleaner that her 2-year-old son drank. Which of the following is the most important instruction the nurse gives to this parent?

3. The nursing assessment on a 78-year-old woman reveals shuffling gait, decreased balance, and instability. On the basis of the patient’s data, which one of the following nursing diagnoses indicates an understanding of the assessment findings?

4. A couple is with their adolescent daughter for a school physical and state they are worried about all the safety risks affecting this age. What is the greatest risk for injury for an adolescent?

5. The nurse found a 68-year-old female patient wandering in the hall. The patient says she is looking for the bathroom. Which interventions are appropriate to ensure the safety of the patient? (Select all that apply.)

6. The family of a patient who is confused and ambulatory insists that all four side rails be up when the patient is alone. What is the best action to take in this situation? (Select all that apply.)

7. A physician writes an order to apply a wrist restraint to a patient who has been pulling out a surgical wound drain. Place the following steps for applying the restraint in the correct order.

8. A child in the hospital starts to have a grand mal seizure while playing in the playroom. What is your most important nursing intervention during this situation?

9. A 62-year-old woman is being discharged home with her husband after surgery for a hip fracture from a fall at home. When providing discharge teaching about home safety to this patient and her husband, the nurse knows that:

    10. A fragile, 87-year-old nursing home resident is admitted to the hospital with dehydration and increased confusion. The patient has upper limb restraints to prevent her from pulling out her nasogastric tube. What instructions does the nurse give to nursing assistive personnel (NAP)?

    11. The nursing assessment of an 80-year-old patient who demonstrates some confusion but no anxiety reveals that the patient is a fall risk because she continues to get out of bed without help despite frequent reminders. The initial nursing intervention to prevent falls for this patient is to:

    12. To ensure the safe use of oxygen in the home by a patient, which of the following teaching points does the nurse include? (Select all that apply.)

    13. How does the nurse support a culture of safety? (Select all that apply.)

    14. You are admitting Mr. Jones, a 64-year-old patient who had a right hemisphere stroke and a recent fall. The wife stated that he has a history of high blood pressure, which is controlled by an antihypertensive and a diuretic. Currently he exhibits left-sided neglect and problems with spatial and perceptual abilities and is impulsive. He has moderate left-sided weakness that requires the assistance of two and the use of a gait belt to transfer to a chair. He currently has an intravenous (IV) line and a urinary catheter in place. What factors increase his fall risk at this time? (Select all that apply.)

    15. At 3 am the emergency department nurse hears that a tornado hit the east side of town. What action does the nurse take first?