Healthcare Safety: Concepts and Medical Errors

Safety Concept

• Safety is freedom from psychological and physical injury
• Safety includes prevention of patient injury from healthcare errors
• QSEN safety competency for nurses minimizes risk of harm to patients and providers through system effectiveness and individual performance

Importance of Healthcare Safety

• Healthcare in the US is not as safe as it should be
• Preventable medical errors in hospitals exceed deaths from motor vehicle accidents, breast cancer, and AIDS
• Preventable medical errors cause 44,000 to 98,000 deaths in hospitals annually

Medical Errors

• Medical errors are the failure to complete a planned action as intended or the use of an incorrect plan
• Common issues occurring during healthcare are adverse drug events, improper transfusions, surgical injuries, wrong-site surgery, suicides, restraint-related injuries, falls, trauma, burns, pressure ulcers, and mistaken patient identities
• Information was published in November 1999

Introduction to Patient Safety

• Healthcare provided safely and in a safe environment is critical for survival and well-being
• Nurses promote patient safety, applying critical thinking

Patient Identification

• Best way to correctly identify a patient is to have them state their name and birthday
• The second method is to check the patient's name bracelet
• Both steps should be completed before patient contact
• Bar scan medications before administering

Scientific Knowledge Base

• Environmental safety protects staff to function optimally
• Basic human needs such as sufficient oxygen, nutrition, and optimum temperature influence a person's safety
• Supplemental oxygen poses a fire risk
• Nutrition requires knowledge of healthy food and food safety
• Extreme temperatures pose safety risks to vulnerable populations
• Physical hazards often result in physical or psychological injury or death
• Motor vehicle accidents are a physical hazard, especially for the elderly
• Poisons can impair the function of major organ systems
• Falls are the second leading cause of accidental or unintentional injury deaths worldwide
• Careless smoking is the leading cause of fire-related deaths

Nursing Knowledge Base

• Factors influencing patient safety include patient developmental level
• Influences include mobility, sensory and cognitive status
• Lifestyle choices and knowledge of common safety precautions

Nursing Process: Assessment

• Nursing assessment includes nursing history and examination
• Assessment includes assessing health care environment for risk of falls or medical errors and disasters
• Assessments also include assessment of a patient's home environment

Nursing Diagnosis

• Nursing diagnoses for patients with safety risk include
  • Risk for falls
  • Impaired home maintenance
  • Risk for injury
  • Impaired cognition: confusion
  • Lack of knowledge
  • Risk for poisoning
  • Risk for Trauma

Nursing Implementation

• Nursing implementation includes environmental interventions
• Interventions cover basic needs and falls safety in the home
• General preventive measures: lighting and changing the environment

Falls

• A patient falls defined as a sudden, unintentional change in position, coming to rest on the ground or other lower level
• Falls are commonly reported as part of adverse hospital events, occurring more than 1 million times annually
• Approximately 30% of falls result in some type of injury with 10% resulting in serious injury like head trauma or fracture
• Falls among older adults are especially dangerous because they can cause increased morbidity and mortality
• Assessing a patient's risk factors for falling is essential in determining specific needs and developing targeted interventions

Fall Assessment Tools

• Morse Fall Scale
• Hendricks II Fall Risk Scale

Morse Fall Scale

• Factors include history of falling, secondary diagnosis, ambulatory aid required, IV/Heparin lock, gait/transferring ability, and mental status
• Scoring: No risk is 0-24, low risk is 25-50, and high risk is ≥ 51
• Interventions corresponding to risk level are, good basic nursing care, implement standard fall prevention interventions, or implement high-risk falls prevention interventions

Hendrick II Fall Risk Model

• Risk factors include confusion/disorientation (4 points), depression (2 points), and altered elimination (1 point)
• Vertigo (1 point) and male gender (1 point), antiepileptics (2 points), and benzodiazepines (1 point) can influence risk
• Get-up-and-go ability factors into risk using a chair.

Fall Precaution: Implementation

• Place the call light within reach
• Set bed alarm
• Apply yellow, non-skid socks before a patient is ambulating
• Place a patient with their stronger side to the handrails when walking
• Electronic devices must be attached to the patient in bed to work correctly

DO NOT USE 4 Side Rails

Bathroom Safety

• To promote safety, bathrooms should have handrails, be well-lit, and have a call light inside
• Doors should remain open

Restraints: Defining Appropriate Use

• Restraints are only appropriate when the client is a danger to themselves or others
• Restraints may be used if a client tries to harm themself, is combative to the team, or is trying to pull out IVs or airways
• Restraints can be used with delirious patients not knowing where they are who are a risk to harming themselves.
• Restraints should be removed as soon as possible with alternative methods of redirection, orientation, or medication.

Acute and Restorative Care: Restraints

• Restraints are devices used to immobilize a client or an extremity and can be physical or chemical
• Restraints are temporary
• Restraints are used to protect a patient from self-injury
• Can be used to prevent violence toward others
• Restraints can deprive a patient of the right to control their own body

Restraints and Alternatives

• Restraints: Any manual method, physical or mechanical device, or material/equipment immobilizes or reduces the ability of a patient to move his or her arms, legs, or head freely
• Restraint Alternatives: Devices or techniques employed to avoid the use of restraints. The intent and how it is used impacts alternatives to restraints

Restraint-Free Guidelines

• Establish a restraint-free standard
• Use the least restrictive but safest environment
• Only clinically appropriate restraint situations should arise because they should not be routine; always evaluate the patient
• Rationale must be documented, and orders are limited in duration to 24 hours.

Risks of Restraints

• Injuries can result from improperly positioned restraints, such as choking from straps and injuries from struggling
• Medical complications from keeping a patient positioned with restraints for a long period can cause poor circulation, incontinence, constipation, weak muscles, and pressure sores
• Mental and emotional problems include depression, agitation, humiliation, and disinterest

When Restraints are Necessary

• Use restraints only when all alternative interventions have been exhausted
• Vital treatments may depend on their use
• Only use restraints if there is a clear and present danger
• IF RESTRAINTS MUST BE USED:
  • Protect the patient's dignity and rights
  • Choose the least restrictive method
  • Document each occurrence of restraint use
  • Properly trained and authorized staff may apply and remove restraints
  • Choose the correct restraint size because if too small, restraints may cause agitation and if too large, the patient can slide down inside in the restraint which could lead to asphyxiation

Initiation of Restraints

• Only an RN may initiate the first-time application of restraints
• A UAP or LPN may remove and reapply restraints as needed for safety and hygiene

Correct Application for Restraints

Documentation and Assessment

• The reason restraints are indicated
• Start and stop times
• A Plan of care
• Assessment, especially to check for skin breakdown; look for redness; provide skin care; release every 2 hours

Restraints Monitoring

• For patients who are behavioral observe every 15 mins for behavior and physical condition
• For medical and surgical patients observe every 2 hours for behaviors and physical conditions
• For both patients offer liquid, nutrition, comfort and bathroom every 2 hours, and remove restraints every 2 hours
• For behavioral patients remove restraints for 5 minutes and for medical/surgical patients remove restraints for 10 mins
• Both patient types should undergo appropriate range of motion and skin care

Options for Restraint Alternatives

Criteria to Discontinue

• Ability of a patient to follow directions, to participate in care and in programs
• Improvement/changes in behavior
• Lines and tubes discontinued
• Positive response to medication intervention

Questions to Ask

• What does the assessment of ADLs include?
• Dressing is the correct response

ADLs and IADLS

• ADLs are activities of daily living that people do everyday
• bathing and grooming, ambulation, transfers, toileting, eating, and dressing
• IADLs are instrumental activities of daily living:
• writing, reading, cooking, cleaning, shopping, doing laundry, going up stairs, using the telephone
• Outside activities, managing medications, managing money, transportation