1. Chapter 19
Safety: Measures that prevent accidents or unintentional injuries

2. OBJECTIVES
1. Discuss the purpose of the National Patient Safety goals and methods for implementing them.
2. Give an example of one common injury that predominates during each developmental stage (infancy through older adulthood).
3. Name six injuries that result from environmental hazards.
4. Identify at least two methods for reducing latex sensitization.
5. List four areas of responsibility incorporated into most fire plans.
6. Describe the indications for using each class of fire extinguishers.
7. Discuss five measures for preventing burns.
8. Name three common causes of asphyxiation.
9. Discuss two methods for preventing drowning.
10. Explain why humans are susceptible to electrical shock.
11. Discuss three methods for preventing electrical shock.
12. Name at least six common substances associated with poisonings.
13. Discuss four methods for preventing poisonings.
14. Discuss the benefits and risks of using physical restraints.
15. Explain the basis for enacting restraint legislation and the Joint Commission’s accreditation standards.
16. Differentiate between a restraint and a restraint alternative.
17. Give at least four criteria for applying a physical restraint.
18. Describe two areas of concern during an accident.
19. Explain why older adults are prone to falling.

3. National Patient Safety Goals
Description: established in 2003 by Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
Purpose: Safe and effective care of the highest quality by reducing the risk of adverse client outcomes.

4. National Patient Safety Goals
Goals are revised annually to reduce the incidences of deaths & injuries among those being cared for in health agencies.
Most hospital deaths & injuries are attributed to medication errors & adverse medication effects, infections, surgical errors.
Text p. 399

5. Safety Major nursing responsibility
Death from hospital errors: ranked between 5th – 8th leading cause of death by National Center for Health Statistics

6. National Patient Safety Goals
Potential methods for implementation (Text p.400) Table 19-1 Summary of Nat’l Patient
Safety Goals
Prevent infection Follow hand-washing & hand antisepsis guidelines (recommended by CDC or WHO)
Use evidence based practices to prevent and treat infections.

7. National Patient Safety Goals
Prevent Infection Promote Flu & Pneumococcal vaccines in older adults
Identify patients 2 methods of ID Correctly before medications/ blood/treatment administration
Improve staff Use only approved Communication abbreviations and symbols (list on page w/medical terms)

8. National Patient Safety Goals
Improve staff Contact appropriate Communication healthcare providers promptly when a client’s health status changes. Repeat or read back verbal & phone MD orders

9. National Patient Safety Goals
Use medications Label all meds. safely Confirm that any new meds are appropriate to take with current meds.
Provide a list of client’s meds to MD, client, family & next healthcare provider prior to discharge.

10. National Patient Safety Goals
Identify clients with Falls Risk, suicide, safety risks fires from O administration & institute precautionary measures
Prevent pressure Determine which
ulcers clients are at risk for pressure ulcers, develop a plan of care, reassess periodically
Involve clients in Inform clients how to their care report safety issues

11. National Patient Safety Goals
Prevent surgical Mark the body errors part, do “time out” checks making sure right client and documentation immediately before surgery. Commonly called OR Checklists

12. Age-Related Safety Factors
Infants
Falling off changing tables
Unrestrained in automobiles
Toddlers
Climbing; accidental poisoning; falling downstairs or from high chairs; burns; electrocution; drowning

13. Age Related Safety Factors (cont’d)
School-aged children and adolescents
School-aged children: play-related injuries
Adolescents: sports-related injuries
Adults: ignoring safety issues, fatigue, sensory changes, effects of disease

14. Environmental Hazards
Latex sensitization
Thermal burns
Asphyxiation
Electrical shock
Poisoning
Falls

15. Question Is the following statement true or false?
Poisoning is a common hazard found only in homes.

16. Answer
False. Poisoning is a common hazard found in the home and health care environment.

17. Environmental Hazards (cont’d)
Latex sensitization: allergic response to the latex proteins
Latex is natural rubber sap
Component of many household items
Predisposition to latex sensitivity (hx. Asthma & allergies to other substances, multiple surgeries, & recurrent medical problems)

18. Environmental Hazards
Latex: a natural rubber sap whose origin is a species of tree indigenous to Brazil. Common Items Containing Latex (Text: 401) Medical gloves IV ports Band-aids Bulb syringes Urinary catheters Wound drains (JP) Tourniquets Endoscopes Mattress covers BP cuffs & tubing - Stethoscope tubing Jobst stockings

19. Environmental Hazards (cont’d)
Types of latex reactions
Contact dermatitis: delayed localized skin reaction; occurs within 6-48 hours & last for several days.
Symptoms include: dry, itchy, irritated areas on the skin, usually the hands

20. Environmental Hazards (cont’d)
Immediate hypersensitivity: instant/quick reaction manifested by swelling, itching, resp distress, hypotension, death in severe cases Sensitized people can develop a cross- reaction to fruits or vegetables: due to the molecular structure of latex and other plant substances are similar

21. Environmental Hazards (cont’d)
Preparing a latex-free room (helps in preventing latex sensitization and allergic reactions)
Stock room with latex-free equipment, including gloves, client care equipment, and resuscitation equipment
Wipe room clean of glove powder
Communicate with other departments the need to use only latex-free equipment

22. Environmental Hazards (cont’d)
How would nurses communicate with other departments regarding a client’s latex allergy? Flagging the chart, room door, attaching an allergy-alert I.D. bracelet

23. Question Is the following statement true or false?
People with latex allergy may develop a cross-reaction to certain foods.

24. Answer
True. People with latex allergy may develop a cross-reaction to certain fruits and vegetables.

25. Environmental Hazards (cont’d)
Examples of fruits a person with a history of a latex allergy could become cross- contaminated with: Avocados Bananas Kiwis Almonds Tomatoes Peaches Because of similar molecular structure of latex and other plants substances

26. Environmental Hazards (cont’d)
Safeguarding clients and personnel
Prevent latex sensitization
If using latex gloves, avoid oil-based hand creams
Wash hands thoroughly after removing gloves

27. Question Is the following statement true or false?
When using latex gloves, a nurse should use
oil-based hand creams.

28. Answer
False. When using latex gloves a nurse should avoid the use of oil-based creams.

29. Why should the nurse avoid oil-based hand creams or lotions?

30. Oil-based hand creams can cause glove deterioration.

31. Environmental Hazards (cont’d)
Burns
Thermal burns: caused by fire, hot liquids, steam and is the most common form for burns
Chemical burns: result from lye, electric wires, lightning

32. Environmental Hazards (cont’d)
Burn prevention: exits identified, lighted, unlocked. Most fire codes require public buildings to have a functioning sprinkler system, flame-resistant fabric, never smoke around O2, do not overload outlets or circuits..
Fire plans: procedures in place for possible/actual fire. Compliance is a major component of JCAHO.

33. Environmental Hazards (cont’d)
One goal JCAHO has when visiting a facility is to ask random employees what that particular facility’s fire code is. Most employees can’t remember, which is why we have training at least annually. How often is up to the facility. This is when the employee gets taught the acronym R-A-C-E. (Text: 402)

34. Environmental Hazards (cont’d)
Burns (cont’d)
Fire management: RACE
Rescue
Alarm
Contain
Extinguish

35. Environmental Hazards (cont’d)
Burns (cont’d)
Roles and responsibilities at and away from fire’s origin
Use of fire alarm system
Agency fire plan concepts

36. Environmental Hazards (cont’d)
Burns (cont’d)
Rescue and evacuation; proper use of equipment
Building compartmentalization for containing smoke and fire
Fire extinguishers

37. Environmental Hazards (cont’d)
Burns (cont’d)
Fire extinguishers
Class A: wood, paper
Class B: liquids, grease
Class C: electrical
Class ABC: combination

38. Evacuation of Clients
The methods listed below correspond with the picture on the following slide:
Human Crutches: rescuers secure a weak, but ambulatory client’s arms and waist
Seat Carry: rescuers interlock arms and carry a non-ambulatory client
Body drag: rescuer drags an unconscious victim or a victim who can’t walk on a blanket or sheet.

39. Evacuation of Clients

40. Environmental Hazards (cont’d)
Asphyxiation (inability to breathe): can result from airway obstruction, drowning, inhalation of gases like carbon monoxide (CO) and smoke.
CO binds with hemoglobin
CO poisoning: symptoms similar to flu, except for cherry-red skin color

41. Environmental Hazards (cont’d)
Box 19-2 Symptoms of Carbon Monoxide Poisoning (Text: 405)
Nausea/vomiting - Muscle Weakness
Headache - Confusion
Dizziness - Shortness of breath
Cherry-red skin color
Lapse into a coma, followed by death

42. Environmental Hazards (cont’d)
What is the treatment of someone suspected of CO poisoning? Get the victim out of the immediate environment. If you can’t get the victim out, the open windows & door for cross ventilation.

43. Environmental Hazards (cont’d)
Extremely high levels of CO, may be treated with hyperbaric (high-pressure) O2, which delivers 100% O2 at 3x the normal atmospheric pressure within an airtight chamber Prevention: Have carbon monoxide detectors installed.

44. Environmental Hazards (cont’d)
Drowning
Fluid occupies airway, interferes with ventilation
Accidental drowning (during water activities)
Resuscitation
Immediate CPR
CPR certification in nurses

45. Environmental hazards (cont’d)
Drowning Prevention
Learn to swim
Never swim alone
Wear an approved flotation device
Do not drink alcohol when participating in water-related sports
Notify law enforcement officer if boaters appear unsafe

46. Environmental Hazards (cont’d)
Electrical shock (discharge of electricity through the body)
Body prone to electric shock because we are made up of H2O and electrolytes, both are good conductors of electricity
Macroshock: harmless distribution of low-amperage electricity over a large area of the body. Feels like a slight tingling

47. Environmental Hazards (cont’d)
Electrical shock
Microshock: Low-voltage but high-amperage, intact skin acts as a barrier, usually not felt; can be fatal, especially if delivered directly to the heart
Measures to prevent electrical shock
Grounded equipment reduces electrical shock potential. (3-prong plug)
Do not use extension cords
Other safety measures are in Text p.406

48. Environmental Hazards (cont’d)
Poisoning
Injury caused by ingestion, inhalation, or absorption of toxic substance
More common in homes than in health care institutions
Accidental poisonings; medication errors

49. Environmental Hazards (cont’d)
Why do more poisonings happen in the home versus healthcare settings?

50. Environmental hazards (cont’d)
Health care facilities keep their medications locked up.

51. Environmental Hazards (cont’d)
Clients in hospitals are not routinely allowed to keep medications at their bedside.
Medications are usually taken upon admission into health care facilities

52. Environmental Hazards (cont’d)
Some Common Substance Associated with Childhood Poisonings
Drugs: ASA, Tylenol, Vitamins with Iron, Antidepressants, Sedatives
Cleaning Agents: Bleach, Drain cleaners
Paint Solvents: Turpentine, gas, kerosene
Heavy metals: Lead pain chips

53. Environmental Hazards (cont’d)
Childhood poisoning agents in the home:
Chemical products: Glue, shoe polish, insecticides
Cosmetics: Hair dye, nail polish remover
Plants: Mistletoe berries, rhubarb leaves castor beans
(Text: Box 19-3 p.406)

54. Environmental Hazards (cont’d)
Childhood poisoning agents: (Sample)
Iron
Look like candy
Parents don’t think Vitamins with Iron can be harmful.
Not kept out of reach of small children

55. Environmental Hazards (cont’d)
Iron Toxicity: Pediatric Iron Toxicity
Phase 1: (1st 6 hours post ingestion): Manifests usually as GI effects such as hemorrhagic vomiting, diarrhea, abdominal pain
Phase 2: (latent phase) 4-12 hours post ingestion: Lab analysis demonstrates progressive metabolic acidosis, beginning of end-organ dysfunction

56. Environmental Hazards (cont’d)
Latent phase: Elevated transaminase levels
(ALT & AST) May indicate liver damage
Phase 3 (12-24 hours post ingestion): Marked systemic toxicity: GI fluid losses lead to hypovolemic shock, coagulopathy
More phases can be looked up at later date
Most exposures: children under 6 with many serious acute occur in children under 3.

57. Environmental Hazards (cont’d)
Poisoning prevention
Educate children; teach parents
Cognitive-impaired adults: use prefilled medication containers
American Association of Poison Control Centers.
Client and Family Teaching 19-2 (p.407)

58. Treatment for Ingested Poisons
Treatment depends on the substance, client condition and if the substance is still in the stomach.
Maintain breathing and cardiac function
Identify substance
Consult Poison Control Center
Figure: 19-6 Decision tree (p.407)

59. Environmental Hazards (cont’d)
Falls
Most common accident with the most serious consequences in older adults
Contributing factors: visual impairments; disorders affecting gait, balance, and coordination; medications to lower blood pressure

60. Environmental Hazards (cont’d)
Falls (cont’d)
Contributing factors (cont’d)
Urinary urgency
Social, environmental factors
Accumulation of clutter
Hospitalization
Confusion, impaired judgment

61. Environmental Hazards (cont’d)
Assessment
Determine risk factors
Fall prevention measures (page 408)
Keep emergency numbers near phone
Daily phone tree
Personal response services

62. Restraints
Physical restraints-protect a client from falling out of bed or permit the client to participate in activities
Chemical restraints-manage a client’s behavior or freedom of movement
Purpose: client or staff safety
Use of restraints is closely regulated
Restraints may not be used for disciplinary reasons
Last intervention used after all others exhausted

63. Restraints (cont’d) Risks of use: Increase client confusion
Cause chronic constipation, incontinence, infections (pneumonia)
May cause pressure ulcers
Experience progressive decline in ability to perform ADLs independently

64. Restraints (cont’d)
Legislation (OBRA: Omnibus Budget Reconciliation Act
Law incorporated; compliance mandatory since 1990
Accreditation standards
Restraint protocol; medical orders; monitoring and documentation

65. Restraints (cont’d)
Restraint alternatives: protective or adaptive devices that promote client safety and postural support which the client can release independently: Seat belts / Harnesses with front releasing Velcro or buckle closures, support pillows, seat inserts
Figure 19-8 Examples of restraint alternatives
(Text p.410)

66. Restraints (cont’d) Other Supplementary Measures
Improve client gait training
Provide physical exercise
Reorient clients
Encourage ambulatory aids (walkers)
Electronic seat & bed monitors (bed alarm)
Position wheelchair bound clients correctly

67. Nursing Implications Recognize safety hazards
Identify clients at greatest risk for injury
Identify several nursing diagnoses
Client safety; allegations of malpractice

68. General Gerontologic Considerations
Number of falls and severity of injury
Falls rob client of independence
Well-fitting enclosed shoes, nonskid soles
Most falls occur in clients 65 years or older, at home

69. General Gerontologic Considerations (cont’d)
Factors contributing to falls in older adults: health conditions; situations such as environmental hazards, inadequate lighting, general clutter, assistive devices
Osteoporosis
Fear of falling; history of falling
Cognitive impairment