ch 19.pdf

Safety Chp 19 Safety (measures that prevent accidents or uninten onal injuries) remains a primary focus in health care since many hospital deaths and injuries are a ributed to medica on errors and adverse medica on effects, infec ons, and surgical errors. The Joint Commission (TJC) began considering...

Safety Chp 19 Safety (measures that prevent accidents or uninten onal injuries) remains a primary focus in health care since many hospital deaths and injuries are a ributed to medica on errors and adverse medica on effects, infec ons, and surgical errors. The Joint Commission (TJC) began considering safety a priority when caring for clients and began establishing Na onal Pa ent Safety Goals (NPSGs) in 2003. Summary of Hospital NPSG Iden fy pa ents correctly. Use at least two ways to iden fy pa ents. For example, use the pa ent’s name and date of birth. This is done to make sure that each pa ent gets the correct medicine and treatment. Improve staff communica on. Get important test results to the right staff person on me. 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 pa ents who take medicines to thin their blood. Record and pass along correct informa on about a pa ent’s medicine. Find out what medicines the pa ent is taking. Compare those medicines to new medicines given to the pa ent. Give the pa ent wri en informa on about the medicines they need to take. Tell the pa ent it is important to bring their up-to-date list of medicines every me they visit a doctor. Use alarms safely. Make improvements to ensure that alarms on medical equipment are heard and responded to on me. Prevent infec on. Use the hand cleaning guidelines from the Centers for Disease Control and Preven on or the World Health Organiza on. Set goals for improving hand cleaning. Use the goals to improve hand cleaning. Iden fy pa ent safety risks. Reduce the risk for suicide. Prevent mistakes in surgery. Make sure that the correct surgery is done on the correct pa ent and at the correct place on the pa ent’s body. Mark the correct place on the pa ent’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 pa ent right and le. Environmental hazards are poten ally dangerous condi ons in the physical surroundings. Examples in the home and health care environment include latex sensi za on, thermal burns, asphyxia on, electrical shock, poisoning, and falls. Increasing numbers of people are developing latex sensi vity (allergic response to the proteins in latex). Contact derma s, a delayed localized skin reac on that occurs within 6 to 48 hours and lasts for several days. Acute hypersensi vity, an instantaneous or prompt systemic reac on 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 preven ng latex sensi za on and allergic reac ons is to minimize or eliminate latex exposure. Common Items Containing Latex         Medical gloves Intravenous injec on ports Band-Aids No disposable sheet protectors Bulb syringes Stethoscope tubing Medica on vial stoppers Tourniquets Urinary catheters Elas c stockings Condoms Ma ress 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 me the gloves are worn. Wash hands thoroughly with a pH-balanced soap a er removing the gloves. Avoid using oil-based hand creams or lo ons. Other measures to protect clients and health care providers include:     Obtain an allergy history and ask about sensi vity to latex. Flag the chart and room door and a ach an allergy alert iden fica on bracelet on latex-sensi ve 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 synthe c gloves and latex-free client care and resuscita on equipment in the room of a client sensi ve 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 Preven on The nurse teaches the client or the family the following:                            Change the ba eries in smoke, heat, and carbon monoxide detectors at least every year. Equip the home with at least one fire ex nguisher. Develop an evacua on plan (and an alternate escape route) and a place for family members to meet a er exi ng a burning home. Prac ce the evacua on plan periodically. Keep all windows and doors barrier-free. Iden fy the loca on 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, turpen ne, or other solvents. Go to public fireworks displays rather than igni ng 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 direc ons 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 le 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 se ng, 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 inspec on. 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 responsibili es at and away from the fire’s point of origin Use of the fire alarm system Roles in preparing for building evacua on. Loca on and proper use of equipment for evacua on or transpor ng clients to areas of refuge. Building compartmentaliza on procedures for containing smoke and fire. To obtain TJC’s accredita on, staff members on each shi must also par cipate in fire drills, the frequency of which must be iden fied in the agency’s fire plan. Fire Management The Na onal Fire Protec on Associa on, whose Life Safety Code is the basis for TJC’s management standards, recommends using the acronym “RACE” to iden fy the basic steps to take when managing a fire: R—Rescue A—Alarm C—Confine the fire. E—Ex nguish Evacuate clients from the room with the fire. Inform the switchboard operator of the fire’s loca on. He or she will alert personnel over the public address system and no fy 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 direc ons. Place moist towels or bath blankets at the threshold of doors if smoke is escaping. Use an appropriate fire ex nguisher 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 a er exi ng. Using a variety of techniques, nursing personnel evacuate those who cannot walk. Fire Ex nguishers There are various types of fire ex nguishers. Each type is labeled. Nurses must know the type of ex nguisher that is appropriate for the burning substance and how to use it. The Na onal Fire Protec on Associa on (2012) recommends remembering the mnemonic “PASS”:     Pull the pin with the ex nguisher in a downward posi on and release the locking mechanism. Aim the nozzle of the ex nguisher at the base of the fire. Squeeze the lever slowly and evenly. Sweep the nozzle from side to side. Asphyxia on (an inability to breathe) can result from airway obstruc on, drowning, or inhala on of noxious gases such as smoke or carbon monoxide (CO). Smoke can be more deadly than fire. It consists of incinerated par cles, chemicals, and gases. Health care facili es have banned cigare e smoking; consequently, smoke inhala on in those loca ons now accounts for far fewer deaths. Types of Fire Ex nguishers 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, cogni ve 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, vomi ng, weakness, and confusion. When CO gases accumulate above 150 to 200 ppm, disorienta on, unconsciousness, and death are possible. One of the classic signs of CO poisoning is a bright cherry red skin color that may persist even a er death occurs. Drowning is when fluid occupies the airway and interferes with ven la on. Therefore, nurses should never leave any helpless or cogni vely impaired client, young or old, alone in a tub of water regardless of its depth. Cardiopulmonary resuscita on (CPR), if begun immediately, may be lifesaving for a vic m of asphyxia on or drowning. Current CPR cer fica on 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 poten al 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 inges on, inhala on, or absorp on of a toxic substance. Acetaminophen overdose is a leading cause of acute liver failure in children. Individuals are o en 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 cogni ve impairments from accidental inges on of toxic substances, such as medica ons and cleaning agents, by keeping all poten ally harmful substances in a secure, locked loca on. 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 Considera ons    Osteoporosis (loss of bone mass) increases the risk of fractures. Osteoporo c fractures may occur with li le 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 cau ous. Fear of falling can significantly limit mobility, which may increase the risk for falls. Prac cal methods such as assessing risk factors for falls and teaching fall management should be ini ated. 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 coordina on. Some take medica ons 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. Iden fying at-risk clients and preven ng 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 sca er rugs. Keep extension cords next to the wall.                Do not wax floors. Wear well-fi ng shoes that enclose the heel and toe of the foot and have nonskid soles. Keep pathways clu er-free. Wear short robes without cloth belts that may loosen and trip the client. Use a cane or walker if prescribed. Replace the p on a cane as it wears down. Stay indoors when the weather is icy or snowy. Sit down when using public transporta on, 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 medica ons that are not a standard treatment or dosage for the client’s condi on but rather are used to manage a client’s behavior or freedom of movement. Remember, chemical restraints are not medica ons commonly included as part of a client’s regimen. Rather, they are medica ons, such as an psycho c agents, given to specifically manage the client’s behavior or freedom of movement. Gerontologic Considera ons    Wandering is not a jus fica on for restraining clients. Older adults who are confused or otherwise cogni vely impaired without an awareness or apprecia on for personal safety may need alterna ve precau ons 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, iden fica on 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 sta ons, allowing the older adult to walk, yet remain in view of the nursing staff.  Caregivers should be aware that early iden fica on is necessary so that proper precau ons can be ini ated. Daily documenta on of what a person is wearing is helpful should the client wander and need to be iden fied.  The Alzheimer’s Associa on sponsors a program called “Safe Return,” which facilitates the repor ng and return of people with cogni ve impairments who become lost. Local police departments may provide a service of digital photography of the older adult and coded iden fica on bracelets. The photos and iden fica on codes are stored in the computers maintained by the police department for iden fica on of an adult found wandering. Clients with demen a may also be fi ed with a global posi oning satellite (GPS) device to facilitate loca ng a missing person. Federal legisla on known as the Nursing Home Reform Law was incorporated in the Omnibus Budget Reconcilia on Act (OBRA) in 1987. Compliance with the law has been mandatory since 1990. The resident (pa ent) has the right to be free from any physical restraints imposed or psychoac ve drug administered for purposes of discipline or convenience, and not required to treat the resident’s (pa ent’s) medical symptoms. … Restraints may only be imposed to ensure the physical safety of the resident or other residents and only upon the wri en order of a physician that specifies the dura on and the circumstances under which the restraints are to be used (except in emergency situa ons which must be addressed in the facility’s restraint policy). A protocol is a plan or set of steps to follow when implemen ng an interven on. During a TJC inspec on, the accredi ng team examines an agency’s protocol for restraint use that the medical staff has approved. The protocol must iden fy the criteria that jus fy the applica on and discon nua on of restraints. Nonphysical interven ons, such as reorien ng a person to place and circumstances, or “ me-out,” which involves removing the client from the immediate environment to a quiet room, is preferred. In the case of a client a emp ng to remove an endotracheal tube that facilitates mechanical ven la on, personnel must first a empt less restric ve 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 a er the restraint is ini ated. 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; circula on; skin condi on or signs of injury; psychological status and comfort; and readiness for discon nuing restraint. The nurse must record nursing care concerning toile ng, nutri on, hydra on, and range of mo on while the client is restrained. The intent of both the OBRA legisla on and the TJC standards is to promote restraint alterna ves (protec ve or adap ve devices that promote client safety and postural support but that the client can release independently) and, eventually, restraint-free client care.