Safety Chp 19.docx

Safety Chp 19 Safety (measures that prevent accidents or unintentional injuries) remains a primary focus in health care since many hospital deaths and injuries are attributed to medication errors and adverse medication effects, infections, and surgical errors. The Joint Commission (TJC) began consid...

Safety Chp 19 Safety (measures that prevent accidents or unintentional injuries) remains a primary focus in health care since many hospital deaths and injuries are attributed to medication errors and adverse medication effects, infections, and surgical errors. The Joint Commission (TJC) began considering safety a priority when caring for clients and began establishing National Patient Safety Goals (NPSGs) in 2003. Summary of Hospital NPSG Identify patients correctly. Use at least two ways to identify patients. For example, use the patient’s name and date of birth. This is done to make sure that each patient gets the correct medicine and treatment. Improve staff communication. Get important test results to the right staff person on time. Use medicines safely. Before a procedure, label medicines that are not labeled. For example, medicines in syringes, cups, and basins. Do this in the area where medicines and supplies are set up. Take extra care with patients who take medicines to thin their blood. Record and pass along correct information about a patient’s medicine. Find out what medicines the patient is taking. Compare those medicines to new medicines given to the patient. Give the patient written information about the medicines they need to take. Tell the patient it is important to bring their up-to-date list of medicines every time they visit a doctor. Use alarms safely. Make improvements to ensure that alarms on medical equipment are heard and responded to on time. Prevent infection. Use the hand cleaning guidelines from the Centers for Disease Control and Prevention or the World Health Organization. Set goals for improving hand cleaning. Use the goals to improve hand cleaning. Identify patient safety risks. Reduce the risk for suicide. Prevent mistakes in surgery. Make sure that the correct surgery is done on the correct patient and at the correct place on the patient’s body. Mark the correct place on the patient’s body where the surgery is to be done. Pause before the surgery to make sure that a mistake is not being made. Remember it is the patient right and left. Environmental hazards are potentially dangerous conditions in the physical surroundings. Examples in the home and health care environment include latex sensitization, thermal burns, asphyxiation, electrical shock, poisoning, and falls. Increasing numbers of people are developing latex sensitivity (allergic response to the proteins in latex). Contact dermatitis, a delayed localized skin reaction that occurs within 6 to 48 hours and lasts for several days. Acute hypersensitivity, an instantaneous or prompt systemic reaction manifested by a variety of signs and symptoms such as swelling, itching, respiratory distress, hypotension, and death in severe cases. One of the best techniques for preventing latex sensitization and allergic reactions is to minimize or eliminate latex exposure. Common Items Containing Latex Medical gloves Intravenous injection ports Band-Aids No disposable sheet protectors Bulb syringes Stethoscope tubing Medication vial stoppers Tourniquets Urinary catheters Elastic stockings Condoms Mattress covers. Wound drains Dental bands Endoscopes Blood pressure cuffs and tubing Use powder-free gloves. Avoid “snapping” the gloves when donning or removing to avoid air dispersal of powder and latex proteins. Reduce the time the gloves are worn. Wash hands thoroughly with a pH-balanced soap after removing the gloves. Avoid using oil-based hand creams or lotions. Other measures to protect clients and health care providers include: Obtain an allergy history and ask about sensitivity to latex. Flag the chart and room door and attach an allergy alert identification bracelet on latex-sensitive clients. Assign clients with latex allergies to private rooms or a latex-safe environment (room stocked with latex-free equipment and wiped clean of glove powder). Stock a latex-safe cart containing synthetic gloves and latex-free client care and resuscitation equipment in the room of a client sensitive to latex. A thermal burn is a skin injury caused by flames, hot liquids, or steam and is the most common form of burn. Client and Family Teaching Burn Prevention The nurse teaches the client or the family the following: Change the batteries in smoke, heat, and carbon monoxide detectors at least every year. Equip the home with at least one fire extinguisher. Develop an evacuation plan (and an alternate escape route) and a place for family members to meet after exiting a burning home. Practice the evacuation plan periodically. Keep all windows and doors barrier-free. Identify the location of exits when staying in a hotel. Dispose of rags that have been saturated with solvents. Keep items away from the pilot lights on the furnace, water heater, or clothes dryer. Avoid storing gasoline, kerosene, turpentine, or other solvents. Go to public fireworks displays rather than igniting them at home. Never smoke when sleepy or around oxygen equipment. Use safety matches rather than a lighter; children are less capable of using matches. Buy clothing, especially sleepwear, made from natural or flame-resistant fabrics. Never run if clothing is on fire; instead stop, drop, and roll. Do not overload electrical outlets or circuits. Set thermostats on hot water heaters to less than 120°F (48.8°C). Keep cords to coffee pots, electric frying pans, or other small cooking appliances above the reach of young children. Follow label directions about the use of gloves when using chemicals. Flush chemicals with copious amounts of water if they meet skin. Go inside if the weather is threatening or you see lightning. If you are inside a burning building: Feel if the surface of a door is hot before opening it. Close doors behind you. Crawl on the floor if the room is smoke-filled. Use stairs rather than elevators. Never go back inside, regardless of whom or what has been left there. Go to a neighbor’s home to call the fire department or 911 operator. Fire Plans To prevent or limit burn injuries in a health care setting, all employees must know and follow the agency’s fire plan (procedure followed for a possible or actual fire). Compliance with the fire plan is a major component of TJC’s inspection. Every accredited health care agency must demonstrate and document that all new and current staff members have been trained in the following five areas: Specific roles and responsibilities at and away from the fire’s point of origin Use of the fire alarm system Roles in preparing for building evacuation. Location and proper use of equipment for evacuation or transporting clients to areas of refuge. Building compartmentalization procedures for containing smoke and fire. To obtain TJC’s accreditation, staff members on each shift must also participate in fire drills, the frequency of which must be identified in the agency’s fire plan. Fire Management The National Fire Protection Association, whose Life Safety Code is the basis for TJC’s management standards, recommends using the acronym “RACE” to identify the basic steps to take when managing a fire: R—Rescue A—Alarm C—Confine the fire. E—Extinguish Evacuate clients from the room with the fire. Inform the switchboard operator of the fire’s location. He or she will alert personnel over the public address system and notify the fire department. Return to the nursing unit when an alarm sounds; do not use the elevator. Clear the halls of visitors and equipment. Close the doors to client rooms and stairwells as well as fire doors between adjacent units. Wait for further directions. Place moist towels or bath blankets at the threshold of doors if smoke is escaping. Use an appropriate fire extinguisher if necessary. The priority is to rescue clients in the immediate vicinity of the fire. Nurses led those who can walk to a safe area and close the room and fire doors after exiting. Using a variety of techniques, nursing personnel evacuate those who cannot walk. Fire Extinguishers There are various types of fire extinguishers. Each type is labeled. Nurses must know the type of extinguisher that is appropriate for the burning substance and how to use it. The National Fire Protection Association (2012) recommends remembering the mnemonic “PASS”: Pull the pin with the extinguisher in a downward position and release the locking mechanism. Aim the nozzle of the extinguisher at the base of the fire. Squeeze the lever slowly and evenly. Sweep the nozzle from side to side. Asphyxiation (an inability to breathe) can result from airway obstruction, drowning, or inhalation of noxious gases such as smoke or carbon monoxide (CO). Smoke can be more deadly than fire. It consists of incinerated particles, chemicals, and gases. Health care facilities have banned cigarette smoking; consequently, smoke inhalation in those locations now accounts for far fewer deaths. Types of Fire Extinguishers and Uses Class A Burning paper, wood, and cloth Class B Fires caused by gasoline, oil, paint, grease, and other flammable liquids. Class C Electrical Fires Class ABC Fires of any kind If superheated gases are inhaled, they can burn the respiratory tract and form carboxyhemoglobin (compound of CO with hemoglobin) in the bloodstream, thereby depriving oxygen to the brain and other vital organs. CO is extremely lethal because it is colorless, odorless, and tasteless, making poisoning with it an “invisible death.” When cells suffer from hypoxia, aerobic metabolism is replaced by anaerobic metabolism, leading to metabolic acidosis and death. If survival occurs, cognitive defects, such as impairment in memory and learning, may persist. The average level of CO in homes is 5 to 15 parts per million (ppm). Prolonged exposure to levels above 70 ppm produces flu-like symptoms such as headache, nausea, vomiting, weakness, and confusion. When CO gases accumulate above 150 to 200 ppm, disorientation, unconsciousness, and death are possible. One of the classic signs of CO poisoning is a bright cherry red skin color that may persist even after death occurs. Drowning is when fluid occupies the airway and interferes with ventilation. Therefore, nurses should never leave any helpless or cognitively impaired client, young or old, alone in a tub of water regardless of its depth. Cardiopulmonary resuscitation (CPR), if begun immediately, may be lifesaving for a victim of asphyxiation or drowning. Current CPR certification is generally an employment requirement for nurses. Many hospitals teach new parents how to administer CPR as well. Must be done on a flat hard surface. Never on a bed. Electrical shock (the discharge of electricity through the body) is a potential hazard wherever there are machines and electrical equipment. If the skin is wet or its integrity is impaired, however, the electrical current can be fatal, especially if delivered directly to the heart. Poisoning is injury caused by the ingestion, inhalation, or absorption of a toxic substance. Acetaminophen overdose is a leading cause of acute liver failure in children. Individuals are often unaware they have exceeded the daily recommended dose of 3 g when fever and pain relief drugs are coupled with over-the-counter cough and cold remedies that also contain acetaminophen. Protect older adults with cognitive impairments from accidental ingestion of toxic substances, such as medications and cleaning agents, by keeping all potentially harmful substances in a secure, locked location. More than any other injury discussed thus far, falls are the most common accident experienced by older adults and have the most serious consequences for this age group. Gerontologic Considerations Osteoporosis (loss of bone mass) increases the risk of fractures. Osteoporotic fractures may occur with little or no trauma and even without a fall. Older adults who have had a previous fall are more likely to fall again and may experience fear of falling, which is characterized by gait changes and being overly cautious. Fear of falling can significantly limit mobility, which may increase the risk for falls. Practical methods such as assessing risk factors for falls and teaching fall management should be initiated. Placing beds at low heights may diminish risks from falls. Many have age-related changes such as visual impairments and disorders that affect gait, balance, and coordination. Some take medications that lower blood pressure, causing dizziness upon rising. Others have urinary urgency and rush to reach the toilet. Determining which clients are at higher risk can prevent some falls. Identifying at-risk clients and preventing falls. The nurse teaches the client, or the family as follows: Keep the environment well lit. Install and use handrails on stairs inside and outside the home. Place a strip of light-colored adhesive tape on the edge of each stair for visibility. Remove scatter rugs. Keep extension cords next to the wall. Do not wax floors. Wear well-fitting shoes that enclose the heel and toe of the foot and have nonskid soles. Keep pathways clutter-free. Wear short robes without cloth belts that may loosen and trip the client. Use a cane or walker if prescribed. Replace the tip on a cane as it wears down. Stay indoors when the weather is icy or snowy. Sit down when using public transportation, even if it means asking someone for his or her seat. Install and use grab bars in the shower and near the toilet. Place a nonskid mat or decals on the floor of the tub or shower. Use soap-on-a-rope or a suspended container of liquid soap to prevent slipping on a loose soap bar. Use a flashlight or nightlight when it is dark. Make sure pets are not underfoot. Mop up spills immediately. Use long-handled tongs rather than climbing on a chair to reach high objects. Physical restraints are methods that immobilize or reduce the ability of a client to freely move his or her arms, legs, body, or head. Chemical restraints are medications that are not a standard treatment or dosage for the client’s condition but rather are used to manage a client’s behavior or freedom of movement. Remember, chemical restraints are not medications commonly included as part of a client’s regimen. Rather, they are medications, such as antipsychotic agents, given to specifically manage the client’s behavior or freedom of movement. Gerontologic Considerations Wandering is not a justification for restraining clients. Older adults who are confused or otherwise cognitively impaired without an awareness or appreciation for personal safety may need alternative precautions to prevent wandering. Helpful devices include placing a specially designed net with a stop sign across the exit doorway with Velcro, using bells over doors to alert caregivers, or disguising an exit door by covering it with a curtain or wallpaper that blends in with the surrounding environment. Several different types of monitors, identification bracelets (that include a phone number), and alert/alarm devices are available to reduce the risk for wandering. Special environments may be designed so that the hallways form a circle around the nursing stations, allowing the older adult to walk, yet remain in view of the nursing staff. Caregivers should be aware that early identification is necessary so that proper precautions can be initiated. Daily documentation of what a person is wearing is helpful should the client wander and need to be identified. The Alzheimer’s Association sponsors a program called “Safe Return,” which facilitates the reporting and return of people with cognitive impairments who become lost. Local police departments may provide a service of digital photography of the older adult and coded identification bracelets. The photos and identification codes are stored in the computers maintained by the police department for identification of an adult found wandering. Clients with dementia may also be fitted with a global positioning satellite (GPS) device to facilitate locating a missing person. Federal legislation known as the Nursing Home Reform Law was incorporated in the Omnibus Budget Reconciliation Act (OBRA) in 1987. Compliance with the law has been mandatory since 1990. The resident (patient) has the right to be free from any physical restraints imposed or psychoactive drug administered for purposes of discipline or convenience, and not required to treat the resident’s (patient’s) medical symptoms. … Restraints may only be imposed to ensure the physical safety of the resident or other residents and only upon the written order of a physician that specifies the duration and the circumstances under which the restraints are to be used (except in emergency situations which must be addressed in the facility’s restraint policy). A protocol is a plan or set of steps to follow when implementing an intervention. During a TJC inspection, the accrediting team examines an agency’s protocol for restraint use that the medical staff has approved. The protocol must identify the criteria that justify the application and discontinuation of restraints. Nonphysical interventions, such as reorienting a person to place and circumstances, or “time-out,” which involves removing the client from the immediate environment to a quiet room, is preferred. In the case of a client attempting to remove an endotracheal tube that facilitates mechanical ventilation, personnel must first attempt less restrictive measures, such as having someone sit with the client. Medical Orders A physician must write a restraint order, or a nurse must obtain one from a physician by telephone within 1 hour after the restraint is initiated. The physician must renew the medical order according to the agency’s protocol. The client’s chart must contain documented evidence of frequent and regular nursing assessments of the restrained client’s vital signs; circulation; skin condition or signs of injury; psychological status and comfort; and readiness for discontinuing restraint. The nurse must record nursing care concerning toileting, nutrition, hydration, and range of motion while the client is restrained. The intent of both the OBRA legislation and the TJC standards is to promote restraint alternatives (protective or adaptive devices that promote client safety and postural support but that the client can release independently) and, eventually, restraint-free client care.