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Chapter 27 Patient Safety Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Safety in Health Care Organizations Performance improvement Risk management and safety reports Current reliable technology Evidence-based practice Safe work environment Adequate staff education Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 2 Quality and Safety Education for Nurses (QSEN) Future nurses need knowledge, skills, and attitudes to promote safety. Continuous improvement is essential. QSEN minimizes risk of harm to patients and providers by System effectiveness Individual performance Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 3 Critical Thinking In patient safety, critical thinking is an ongoing process. Standards have been developed by American Nurses Association and The Joint Commission. Use of the nursing process when planning care promotes safety. Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 4 Safety in Health Care Settings Reduces the incidence of illness and injury Prevents extended length of treatment/stay Improves or maintains functional status Increases patient’s sense of well-being Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 5 A Safe Environment Includes meeting patients’ physical and psychosocial needs Applies to all places where patients receive care Includes patients’ and health care providers’ well-being Reduces risk of injury and transmission of pathogens Maintains sanitation and reduces pollution Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 6 Basic Human Needs Oxygen Temperature Low concentration High concentration Carbon monoxide Normal Hyperthermia Hypothermia Nutrition Proper storage Proper refrigeration Preparation area Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 7 Case Study Mr. Gonzales is a 68-year-old man who has lived alone in a senior apartment building since his wife died 6 months ago. He and his wife were born in Mexico but came to live in the United States shortly after they were married. He is retired from a produce warehouse, where he worked for 37 years. They have raised 3 sons; the closest son, Carlos, is 30 minutes away by car. Carlos visits Mr. Gonzales every week to socialize and take him shopping. Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 8 Environmental Hazards Physical hazards: Lighting Obstacles Bathroom hazards Motor vehicle accidents Poison Fires Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 9 Quick Quiz! 1. While caring for a child, you identify that additional safety teaching is needed when a young and inexperienced mother states that A. Teenagers need to practice safe sex. B. A 3-year-old can safely sit in the front seat of the car. C. Children need to wear safety equipment when bike riding. D. Children need to learn to swim even if they do not have a pool. Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 10 Environmental Hazards Falls Transmission of pathogens Pollution Disasters Natural Man-made Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 11 Case Study (cont’d) Mr. Gonzales is generally healthy but has decreased visual acuity, hearing loss from the noisy warehouse job, and some “arthritis.” He expects to live at least as long as his father, who lived to be 92 years old. Since his wife’s death, Mr. Gonzales has attended Catholic mass every day at his parish church, where his wife had attended daily. Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 12 Safety Risks by Developmental Stage Children younger than 5 years of age School-aged child Adolescent Adult Older patient Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 13 Nursing Knowledge Base Factors influencing safety: Developmental stages Individual risk factors • Mobility, sensory, and cognitive status • Impaired mobility • Lifestyle choices • Lack of safety awareness Risks in the health care agency Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 14 Case Study (cont’d) Joani Green, a 25-year-old married mother of two, is currently a nursing student at the local college. As part of the clinical environment, she and her study partner are conducting health screenings and providing health promotion education for the residents of apartments where Mr. Gonzales lives. Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 15 National Quality Forum List of serious reportable events (SREs) Surgical events Product or device events Patient protection events Care management events Environmental events Criminal events Procedure to report an event Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 16 CMS list of “Never Events” “Never events” should never occur. The Centers for Medicare and Medicaid Services (CMS) now denies hospitals higher payments resulting from or complicated by a “never event.” Many hospital-acquired conditions are nurse sensitive indicators. Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 17 Risks in Health Care Agencies Chemical use (Material Safety Data Sheets [MSDSs]) Medical errors Medication errors Infection Bed sores Failure to diagnose and treat in time Falls Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 18 Risks in Health Care Agency (cont’d) Classification of health care agency accidents: Patient-inherent accidents Procedure-related accidents Equipment-related accidents Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 19 Safety and the Nursing Process Assessment Through the patient’s eyes Patient’s home environment Assessment questions • Activity and exercise • Medication history • History of falls • Home maintenance and safety Nursing history Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 20 Safety and the Nursing Process (cont’d) Assessment (cont’d) Health care environment • Risks in immediate environment • Risk for falls • Risk for medication errors • Disaster preparedness Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 21 Diagnosis Nursing diagnoses for patients with safety risk: Risk for falls Impaired home maintenance Risk for injury Deficient knowledge Risk for poisoning Risk for suffocation Risk for trauma Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 22 Case Study (cont’d) Joani has also discovered through the screening that Mr. Gonzales has decreased visual acuity and has not had a new pair of glasses for 3 years. He fell in his apartment about a month ago but did not have any injuries. Gait assessment reveals that Mr. Gonzales does not pick his feet very high up off the floor, and his movements are stiff. Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 23 Safety and the Nursing Process: Planning Goals and outcomes Prevent and minimize safety threats Are measurable and realistic May include active patient participation Setting priorities Teamwork and collaboration Goals for Mr. Gonzales Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 24 Safety and the Nursing Process: Implementation Health promotion Individualization of implementation Developmental stage Lifestyle Environment Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 25 Safety and the Nursing Process: Implementation (cont’d) Basic needs General preventive measures Lighting Changing the environment Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 26 Case Study (cont’d) The son, Carlos, has purchased a medication organizer that Mr. Gonzales has not used because he is concerned he will make a mistake. Mr. Gonzales is unable to read the labels on his medication bottles. What additional interventions are justified as a result of Mr. Gonzales’ safety assessment? Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 27 Implementation in Acute Care Safety Fall risk prevention Restraints as a last resort Restraint alternatives Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 28 Safety and the Nursing Process: Implementation Acute care safety Seizures Poisoning Electrical hazards Radiation Disasters Hospitals must have an emergency management plan. Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 29 Implementation Acute care safety Fires: “RACE” and “PASS” • Rescue patients. • Activate alarm. • Confine fire. • Extinguish. Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 30 Implementation (cont’d) Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 31 Quick Quiz! 2. A newly admitted patient was found wandering the hallways for the past two nights. The most appropriate nursing interventions to prevent a fall for this patient would include A. Raise all four side rails when darkness falls. B. Use an electronic bed monitoring device. C. Place the patient in a room close to the nursing station. D. Use a loose-fitting vest-type jacket restraint. Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 32 Case Study (cont’d) What additional health behavior can be encouraged for Mr. Gonzales? What effects could this health behavior produce? Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 33 Safety and the Nursing Process: Evaluation Through the patient’s eyes Are the patient’s expectations met? Are the family’s expectations met? Patient outcomes Monitor care by the health care team. Measure outcomes for each diagnosis. Continually assess needs for additional support. Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 34 Case Study (cont’d) It has been 2 weeks since Joani implemented the plan of care for Mr. Gonzales. Joani will observe Mr. Gonzales’ environment for elimination of threats to patient safety. She will reassess motor, sensory, and cognitive status for appropriate environmental modifications. Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 35 Quick Quiz! 3. A nurse floats to a busy surgical unit and administers a wrong medication to a patient. This error can be classified as A. A poisoning accident. B. An equipment-related accident. C. A procedure-related accident. D. An accident related to time management. Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 36 Case Study (cont’d) With regular exercise, Mr. Gonzales has found that his walking has improved, and now he feels safer about leaving the apartment. The new medication labels and organizer have made it easier for him to tell his several medications apart. He reports that his vision is much better with his new glasses. He understands that he is able to make changes in his environment that will keep him safe. Mr. Gonzales has been injury free and plans to live to a “ripe old age.” Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 37 Expected Outcomes A safe physical environment A patient whose expectations have been met A patient who is knowledgeable about safety factors and precautions A patient free of injury Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 38