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10 Patient Safety Tips for Hospitals

Medical errors may occur in different health care settings, and those that happen in hospitals can have serious consequences. The Agency for Healthcare Research and Quality, which has sponsored hundreds of patient safety research and implementation projects, offers these 10 evidence-based tips to prevent adverse events from occurring in your hospital.

Patient safety topics

Patient safety resources are categorised using these topic headings:

Abuse/aggression and patient safety Consent, communication, confidentiality Documentation and patient safety (including checklists/patient records) Environment and patient safety (including cleaning, PEAT) Human factors and patient safety culture (including Seven Steps, teamwork, staffing) Medical devices/equipment Medication safety Patient accident (including slips, trips and falls) Patient admission, transfer, discharge (including patient ID) Patient assessment and diagnosis (including tests, scans) Patient treatment/procedure (including nutrition) Risk assessment and patient safety

Patient safety is one of the nation's most pressing health care challenges. A 1999 report by the Institute of Medicine estimates that as many as 44,000 to 98,000 people die in U.S. hospitals each year as the result of lapses in patient safety. There are things you can do to help yourself get safer health care. Some are as simple as making sure that when you are in the hospital your wristband has the right name on it. Other ways to reduce risks are:

Ask questions if you have doubts or concerns. Take a relative or friend to help you ask questions and understand answers Make sure you understand what will happen if you need surgery Tell your health care providers about all the medicines you take, including over-thecounter drugs and dietary supplements, and any allergies or bad reactions to anesthesia. Make sure you know how to take your medications correctly. Get a second opinion about treatment options Keep a copy of your own health history

Medication safety
Medication incident reports are those which actually caused harm or had the potential to cause harm involving an error in the process of prescribing, dispensing, preparing, administering, monitoring or providing medicines advice.

Over 90 per cent of incident reported to the NRLS are associated with no harm or low harm.

The most frequently reported types of medication incidents involve:

wrong dose omitted or delayed medicines wrong medicine

Incident reports concerning side effects of medicines and defective products should be sent to the Medical and Healthcare Products Regulatory Agency (MHRA).

Abuse, aggression and patient safety

Patients with mental health issues and learning difficulties are amongst the most vulnerable patients to care for. They can also be challenging and exhibit abusive or aggressive behaviour.

Studies of patient safety incidents in mental health settings have highlighted that violence and aggression incidents disproportionately affect mental health patients.

Violence and aggression in mental health units is a complex issue with a variety of antecedents, behaviours and consequences. Violence is a major concern for staff and patients. In particular, service users often feel unsafe on wards, yet the purpose of inpatient care is to provide a safe, therapeutic environment.

In 2006, the National Reporting and Learning Service reported on patient safety in mental health settings in its publication With safety in mind, which analyses incidents of disruptive or aggressive behaviour.

Consent, communication, confidentiality

Communication is a key factor in preventing patient safety incidents and also in learning from them afterwards. Communication includes the mechanics of communication as well as actually talking to one another.

It is one of the key themes of the Seven Steps to Patient Safety, which encourages healthcare organisations to involve and communicate with patients and the public, as well as learning and sharing safety lessons.

The National Reporting and Learning Service has developed a range of resources to help healthcare professionals communicate more effectively, both between themselves and with patients and their families.

These include:

Alerting all acute trusts to use a standard crash call number Reporting on bleep-related incidents Recommending better inter-departmental communication, for example, with radiological imaging results, or for the estates department to inform the renal unit of any changes to the water supply Being Open, a policy which provides guidance for healthcare staff in talking to patients and their families after a patient safety incident

Documentation and patient safety

Correct and up-to-date documentation is essential to help prevent patient safety incidents. Documentation includes patient records and patient identification.

Incidents relating to documentation include:

Patients being incorrectly identified, or nor identified at all, are at risk of being mismatched to their care. They may receive the wrong treatment or may not be treated at all. Patients who require regular blood transfusions are at particular risk of having the wrong blood type administered (ABO incompatibility). This means they need more stringent identification and checks.

The National Reporting and Learning Service has produced resources to help healthcare organisations avoid patient safety incidents by producing correct and up-to-date patient documentation.

Healthcare environment and patient safety

A clean and safe environment is essential for infection prevention and control. It is a key priority for the NHS and is a core standard in the Department of Health document Standards for better health.

This key priority, coupled with concern about healthcare-associated infections (HCAIs), means that hospitals need to be clean and able to demonstrate their standards of cleanliness. Standards and colour coding need to be consistent and measurable. A clean environment also includes good hand hygiene.

The National Reporting and Learning Service has developed resources to help healthcare organisations achieve and monitor environmental and cleanliness standards. These include:

cleanyourhands, a campaign to help healthcare organisations reduce HCAIs via better hand hygiene Creating and implementing consistent national standards, for example, colour coding, and specifications for cleanliness in the NHS Requiring hospitals to measure and report on their environmental standards each year, using Patient Environment Action Team matrices.

Human factors and patient safety culture

Designing healthcare facilities, equipment and the delivery of care around an understanding of human behaviour is vital to reduce the potential for human error.

This also helps healthcare staff to act as a barrier against harm. Human factors is a broad discipline which studies the relationship between human behaviour, system design and safety.

A safety culture is where staff within an organisation have a constant and active awareness of the potential for things to go wrong. Both the staff and the organisation are able to acknowledge mistakes, learn from them, and take action to put things right.

To reduce the likelihood of incidents occurring, patient safety needs to be addressed at an institutional level, from trust board to ward, as well as by designing out errors in processes and equipment.

The National Reporting and Learning Service (NRLS) encourages healthcare organisations to foster a culture of patient safety and to consider human factors when designing and implementing systems and process.

Safer medical devices/equipment

The term medical device includes all products, except medicines, used in healthcare for the diagnosis, prevention, monitoring or treatment of illness or disability.

The range of products is very wide: it includes dressings, tubing, syringes, infusion pumps, heart valves, surgical instruments, resuscitators, radiotherapy machines, wheelchairs, walking frames or other assistive technology products.

Incident reports about defective medical devices should be reported to the Medicines and Healthcare Products Regulatory Agency (MHRA).

Patient safety incidents concerning the use of medical devices should be reported to the National Reporting and Learning Service.

The NRLS has developed a range of resources to help healthcare organisations reduce the risks when using medical devices or equipment. Resources include:

Actions to reduce the risk of harm, such as during use of nasogastric tubes, chest drains, suprapubic or urinary catheters Actions to reduce the risk of infection, such as ventilator-associated pneumonia or central venous catheter-associated bloodstream infections (the Matching Michigan initiative) The Safer Connectors project, which aims to introduce safer connectors for spinal and epidural (neuraxial) medical devices

Patient accident and falls

It is estimated that patient slips, trips and falls cost the NHS approximately 15 million per year. However, recent research has shown that by using a range of simple interventions, healthcare organisations can significantly reduce the number and cost of patient accidents

Three key areas are:

Prevention: understanding the causes and circumstances of previous accidents; identifying and assessing vulnerable patients and implementing a range of interventions Reducing harm: promptly and effectively treating any injury resulting from a slip, trip or fall

Learning from circumstances: continually reviewing and learning from local risk management systems to understand where, when and why patients are most vulnerable to falls

The National Reporting and Learning Service works closely with other organisations to gather information and produce resources aimed at reducing the number of patient accidents, in hospital and community settings.

Patient admission, transfer and discharge from hospital

Patients safety incidents can occur during the patient journey, which includes access, admission, transfer, and discharge. Accurate patient identification is vital.

In particular, patients are sometimes discharged before they are medically or functionally fit and this can put them at risk once they leave hospital.

Use the box below to search for resources relating to the patient journey

Patient assessment and diagnosis

Correct clinical assessment and diagnosis of a patients condition are essential in ensuring they are safely treated.

The National Reporting and Learning Service (NRLS) receives a number of reports of incidents that relate to misdiagnosis or incorrect clinical assessment.

For example, incorrect assessment before surgical procedures that put the patient at risk of harm, such as using bone cement for hip fractures.

Other incidents reported relate to tests or scans not being requested promptly or not being sent in a timely manner.

The NRLS has published guidance and advice to help healthcare organisations carry out correct clinical assessment and diagnosis.

Patient care and treatment (including nutrition)

The National Reporting and Learning Service (NRLS) has produced resources to address a wide range of safety issues that can occur during patient treatment or procedures. This is in response to reports of patient safety incidents submitted to the Reporting and Learning System (RLS) from the NHS in England and Wales.

Resources include specific advice and guidance regarding surgery, for example the WHO surgical safety checklist.

Other resources include:

a series of factsheets regarding hospital nutrition advice on caring for patients with specific needs, such as laryngectomees recommendations for healthcare staff on identifying acutely ill patients who are deteriorating

Risk assessment/management

Risk assessment is the process that helps organisations understand the range of risks they face, the level of ability to control those risks, their likelihood of occurrence and their potential impacts.

Integrated risk management means lessons learned in one area of risk can be quickly spread to another area of risk.

If risks are properly assessed and managed, this can help set all priorities for NHS organisations, teams and individuals, and improve decision-making to reach a balance of risk, benefit and cost.

The National Reporting and Learning Service (NRLS) has produced a range of resources to help managers and staff with risk assessment/management relating to patient safety, including:

A risk management programme, which comprises an overview, and specific guides for practice-based commissioning and commissioners of out-of-hours services Healthcare risk assessment made easy, which promotes vigilance in identifying risk and the ways in which risk can be minimised A risk matrix for risk managers, which helps NHS risk managers implement an integrated system of risk assessment

In addition to these documents, many of the resources listed below will help healthcare staff assess and manage risks to their patients in many scenarios.

Medication administration
1. Right drug 2. Right patient 3. Right dose 4. Right Route 5. Right Time and frequency 6. Right documentation 7. Right history and assessment (complete patient drug/relevant history) 8. Right to approach and right to refuse ( 9. Right drug-to-drug interaction and evaluation (drug-food incompatibilities and drug

interaction) 10. Right Education and information (teach pt. about the drug he is taking)

The Most Common Medication Errors

Medical Author: Melissa Conrad Stoppler, MD Medical Editor: Jay W. Marks, MD Approximately 1.3 million people are injured annually in the United States following so-called "medication errors". The National Coordinating Council for Medication Error Reporting and Prevention defines a medication error as "any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer...related to professional practice, health care products, procedures, and systems, including prescribing; order communication; product labeling, packaging, and nomenclature; compounding; dispensing; distribution; administration; education; monitoring; and use." The U.S. Food and Drug Administration (FDA) currently reviews medication error reports that come from drug manufacturers and through MedWatch, the agency's safety information and adverse event reporting program. The agency also receives reports about medication errors from the Institute for Safe Medication Practices (ISMP) and the U.S. Pharmacopeia. What kinds of errors are most common? In a study by the FDA that evaluated reports of fatal medication errors from 1993 to 1998, the most common error involving medications was related to administration of an improper dose of medicine, accounting for 41% of fatal medication errors. Giving the wrong drug and using the wrong route of administration each accounted for 16% of the errors. Almost half of the fatal medication errors occurred in people over the age of 60. Older people may be at greatest risk for medication errors because they often take multiple prescription medications. How can you help prevent medication errors? When your doctor gives you a prescription, ask him or her to tell you the name of the drug, the correct dosage, and what the drug is used for. Be sure you understand the directions for any medications you may be taking including the correct dosage, storage requirements, and any special instructions. In the hospital, ask (or have a relative or friend ask) the name and purpose of each drug you are given. Be sure to tell your doctor the names of all the prescription and non-prescription drugs, dietary supplements, and herbal preparations you are taking every time he or she writes you a new prescription. This will help to prevent another type of medication problem, undesirable and potentially serious interactions among medications.

Finally, never be afraid to ask questions. If the name of the drug on your prescription looks different than you expected, if the directions appear different than you thought, or if the pills or medication itself looks different, tell your doctor or pharmacist right away. Asking questions if you have any suspicions at all is a free and easy way to ensure that you don't become the victim of a medication error. References: U.S. Food and Drug Administration, "Medication error reports." U.S. Food and Drug Administration. "Strategies to reduce medication errors." The Ten Rights of Safe Drug Administration Guest Author - Cheryl Pombriant, R.N. There are times in a nurse's career when they may need to go back to the basics of nursing and review the very fundamentals of nursing. The very first thing a new nurse has drilled in to her or him before they give medication is The Five Rights of Safe Drug Administration. One of the oaths physicians take is to do no harm to a patient. However, this is an oath that everyone working in health care should abide by and follow with a passion. It is easy to go about the day and have so many deadlines and time restraints. Health care facilities may be short staffed because of call outs or worse yet, budget restraints that have forced the facility to reduce their workforce. Ultimately it is the patient that may suffer as a result of rapid changes and challenges confronting health care. However, if nurses can just take enough time to stop for a few minutes and think, what is best for the patient? The answer will always be clear. So, what is best for the patient? Again, the most important thing to remember is to do no harm. When giving medications to a patient in any setting, it is best to remember the basics of giving medication safely so there will be no errors or adverse events. Thus preventing harm to a patient. So what are the patients rights regarding safe administration of medications? At one time there were only five rights. The right patient, right medication, right dosage, right route, and right time. Now there are The Ten Rights of Safe Drug Administration. The other five rights are right documentation, right education, right to refuse medication, right assessment, and right evaluation. Lets use an example of a patient to receive Lopressor 25mg orally. The order is written for John March to receive Lopressor 25mg orally twice a day for a diagnosis of hypertension. The order is transcribed to the medication administration report (MAR) or the electronic MAR. The process should start here by having another nurse check that the order was transcribed

correctly to the MAR, and the patient is not allergic to Lopressor or any other medications. As the medication is removed it should be checked that in fact the patient you are dispensing it to is John March, the medication is Lopressor, the dosage is 25mg orally, and the time to be given is correct. If you are able to take the medication order with you to the bedside, do so. Identify the patient by his name; ask to have him repeat his name, checking his identification band at the same time, along with correct date of birth. It would also be acceptable to ask if the patient has any allergies and to tell the patient what medication he is being given, the dosage and the route. Hopefully while this is all being performed the nurse is doing a quick visual assessment of the patient. Imagine this patient is elderly and frail, but alert and oriented. All the above rights are completed correctly. The nurse has educated the patient by teaching what the medication is prescribed for and why the physician has ordered it. However, the initial visual assessment has revealed the patient to be more fatigued and appears lethargic. Vital signs are taken and questions are asked regarding how the patient is feeling. The blood pressure is 90/50 and the heart rate is 50. The patient states he does not think he wants to take the medication because he is already feeling not himself. The assessment and evaluation of the patient and medication has suggested potential adverse effects of Lopressor. Thus, suggesting the dosage should be placed on hold at this time and to notify the physician immediately. Documentation supports the clinical findings. New orders have been ordered with parameters for heart rate and blood pressures so the medication can be withheld if needed. Now imagine if you will that the dosage for Lopressor was still 25mg but it was given as an intravenous dose. The nurse did do a quick visual assessment but felt she was too busy to do vital signs and a more thorough assessment. The patient stated he did not feel quite himself and did not want any medication, but because he was frail and elderly the nurse dismissed his comments. The Lopressor was given intravenous and the patient immediately became dangerously hypotensive and bradycardic. Resuscitative measures were needed and the patient was transferred to the ICU. All of this because the right route, right assessment, right evaluation, and right to refuse medication were not performed. It does not matter the reasons why the medication was still given and why the 10 rights of medication safety where not abided by. What matters is harm was done to the patient and what was best for the patient was not considered. When in doubt always ask yourself theses two questions. Could this do harm to my patient? Is this what is best for my patient? These two questions will always guide you in the right direction.

Nurses' perceptions of why medication administration errors occur

Medication administration is a complex and time-consuming task, occupying up to one-third of nurses' time (Pepper, 1995). Because of the complexity of the medication administration process, there is much potential for error. Since nurses actually administer the medication to the patient, they often assume or are assigned responsibility for these errors; however, the actions of everyone involved in the system and the system design itself contribute to errors. While the literature has focused on error-reporting systems and ways to prevent errors, relatively little attention has been paid to why errors occur. The five rights of medication administration (right drug, dose, route, patient, time) are considered the gold standard for assessing medication administration performance, but compliance with them does not exclude other types of errors or reasons why errors occur. Reasons for medication administration errors may include nurse error, system design (medication administration system, drug company practices), and the actions of physicians, pharmacists, and other nurses. Because of the central role nurses play in medication administration, it is important to understand nurses' perceptions of why errors occur to provide a basis for preventing errors. The responses of a large sample of nurses to a survey designed to measure perceptions of why medication administration errors (MAEs) occur are presented. The implications of the results for preventing medication errors in the future are discussed.
More Articles of Interest

Getting to the root of medication errors: Survey results Best practices for safe medication administration AORN's Safe Medication Administration Tool Kit Best practices for safe medication administration Advanced medication administration skills

Background Several reasons have been proposed for why medication Administration errors occur. These reasons generally fall into the following categories: (a) inadequate knowledge and skills, (b) failure to comply with policy and procedure or lack of procedures, (c) failure in communication, and (d) individual and systems issues (Fuqua & Stevens, 1988). Inadequate knowledge and skill generally reflect lack of patient knowledge, patient's diagnosis, and the names, purposes, and correct administration of the medication (Fuqua & Stevens, 1988; Gardner, 1987a & b), but can also include not knowing how to operate IV pumps/infusion devices, mistaking IV lines for NG tubes, and failure to adequately prepare medications before administration (Gardner, 1987a & b). Monitoring errors may also be included in this category (failure to monitor for side effects because of lack of knowledge). Failure to comply with policies and procedures is usually the lack of attention to safeguards in medication administration procedures intended to prevent errors, including such things as not checking patient identification or allergy identification wristbands, not checking the medication against the medication administration record (MAR) (Fuqua & Stevens, 1988), and receiving medications late from the pharmacy (Walters, 1992). Lack of standard protocols for the

administration of high-risk medications such as respiratory muscle relaxants, chemotherapy, and anti-arrhythmics (Gardner, 1987a) may also result in MAEs. The third category of reasons why MAEs may occur is failure in communication. This may include transcription errors, use of abbreviations, illegible handwriting, incorrect interpretation of physician's orders, use of verbal orders, failure to document medications given or omitted, and unclear MARs (Fuqua & Stevens, 1988; Gardner, 1987a & b; Leeuwen, 1994; Walters, 1992). Inadequate order writing by physicians is also a potential source of failure to adequately communicate (Anderson, 1971; Larson, Scott, & Kaplan, 1983). In one study of 865 medication orders written in a 24-hour period, only 92.7% of the orders stated the dose, 90% specified route of administration, 87.9% stated the frequency of administration, 83% of 276 PRN orders stated the indication for the medication, and over 50% of the orders were written using abbreviated names for the medication (Larson et al., 1983). The fourth category of reasons why medication errors may occur includes individual and systems issues, such as number of years of experience of the nurse, number of consecutive hours worked, rotating shifts, workload, distractions and interruptions (Fuqua & Stevens, 1988; Walters, 1992), floating nurses to unfamiliar units, and hospital and pharmacy-design features (Leeuwen, 1994). Finally, drug manufacturers contribute to medication errors by producing look-alike and sound alike drug names, confusing and unclear labeling, packaging of doses (for example, multidose vials, similar packaging for different medications), design of delivery systems, or failure to specify drug concentrations on dose-calculation charts (Fuqua & Stevens, 1988; Gardner, 1987a & b). Building on the information available in the literature, this study sought to determine nurses' perceptions of the reasons for MAE to contribute to our understanding of the medication administration process. Methods Site and subjects. Nurses from a convenience sample of 24 of Iowa's acute care hospitals were surveyed during the spring of 1994. Hospitals were contacted and asked to participate in the survey and to determine which nursing units and nursing staff would receive a survey. To ensure respondent confidentiality, all completed surveys were returned directly to the authors for data cleaning, coding, entry, and analysis. Participating hospitals subsequently received reports in which the responses from the hospital were summarized and compared to the aggregated responses from the other participating hospitals. While in the majority of participating hospitals all nurses working on each nursing unit were given a survey, some hospitals selected a sample of units and staff to receive the surveys. Thus, this study can best be described as using a nonrandom selected convenience sample of nurses working in 24 acute care hospitals. Measures. The survey instrument was initially developed and pilot tested in one hospital as an internal quality improvement initiative. The instrument was developed by an experienced quality improvement clinician and a health services researcher. Items were constructed to reflect the most common reasons for MAE based on the literature. It was then reviewed by a panel of nurses and, following revisions, pilot tested on several nursing units. After minor revisions, the survey was distributed to the study hospitals. The instrument requires respondents to indicate their level of agreement using a six-point Likert-type scale with anchor values of 1=strongly disagree and

6=strongly agree with 18 statements designed to reflect different reasons why medication administration errors occur. The survey also included demographic information such as education, type of nursing unit, and position (staff nurse, head nurse, other). Analysis strategy. The primary focus of the analysis presented in this article is to describe nurses' perceptions of reasons why medication administration errors occur. The unit of analysis is the individual nurse. Descriptive statistics are used to analyze responses to the individual items and describe respondents' characteristics. Principle components factor analysis using orthogonal rotation was used to determine if the individual questions could be combined into subscales. Items found to load together on the same factor were formed into subscales in which each item was equally weighted. Subscale values were calculated by adding the value of each questionnaire item in the scale and dividing by the number of items in the subscale. Subscale reliability was assessed using Cronbach's coefficient alpha. All analyses reported here were conducted using the Statistical Analysis System (SAS). Results Sample characteristics. Survey responses were received from 1,384 nurses, including 304 in 14 rural, 345 in rural referral, and 735 nurses in urban acute care hospitals. Overall, approximately 22% of respondents were from rural hospitals, 25% from rural referral hospitals, and 53% from urban hospitals. For those indicating their education level, respondents included: 107 LPNs (7.7%), 935 ADN or diploma RNs (67.6%), 259 BSNs (18.7%), and 14 advanced degree RNs (1%). Sixty-nine respondents (5%) did not indicate their education level. Approximately 78% of respondents indicated they were staff nurses while 8.9% indicated they held some type of management position (for example, head nurse, nurse managers). A total of 175 respondents (12.6%) did not identify their position in the hospital.

1. Proper Transfer Techniques


Use lifts, transfer boards, adjustable beds and gait belts. Medicare may cover the cost of a lift or hospital bed for a bed-bound patient in the home setting. The 2002 study, "An ergonomic comparison between mechanical and manual patient transfer techniques" found that "manual patient transfer and repositioning techniques are a significant cause of low back injuries," and showed that using lifts placed less stress on the low back than manual patient transfer techniques. Promote patient independence during transfers. In "Evidence-Based Practices for Safe Patient Handling and Movement," Registered Nurse Audrey Nelson and Medical Assistant Andrea Baptiste state, "Patients should be encouraged to assist in their own transfers and handling aids must be used whenever possible." Some patients are capable of performing their own transfers using a mechanical lift. Learn proper body mechanics. This is not as effective as using assisting devices for injury prevention, but it does lower risk.

Team lifting reduces injury risk if more than one person is available.

2. Ineffective Patient Transfer Strategies


Occupational Safety and Health Administration studies have shown that using back belts will not prevent injury. The American Nursing Association finds that nursing school curricula are teaching outdated transfer techniques that rely too heavily on manual lifting and do not familiarize caregivers with lift-assist devices.

Read more: Proper Patient Transfer Technique |

HEALTHCARE WORKERS PATIENT HANDLING Musculoskeletal Injury Among Health Care Workers:

According to the Canadian Labour Force Survey, nurses have the highest number of lost workdays and the highest percentage of lost work time attributable to illness and injury among the major occupational groups in Canada.(1) Occupational back injuries are a serious problem worldwide, accounting for considerable morbidity and cost. (2) In a Canadian study that monitored the health of nurses in Canada, 90 % of study participants cited muscu loskeletal conditions/injuries as a major health concern for nurses.(3) Patient lifts and transfers were found to be the most common cause of reported back injury among health care workers. (4)

What Causes Musculoskeletal Injury?

A single high load incident. Awkward postures for sustained periods of time. Lifting continuously all day long without significant rest of the tissues. Chronic strain to muscles and joints. Imbalance of activities: repetitive and sustained activities in one direction. Stressful living: smoking and poor nutrition. Repetitive wear and tear: reduction of spine's flexibility. Psychosocial factors: time pressures, monotonous work, heavy responsibilities, too many tasks, not enough breaks from work, low control, little autonomy, poor social support from peers and supervisors. (5)

Common Back Musculoskeletal Disorders Strained Ligaments High, fast forces such as slipping and falling on your behind can tear or strain ligaments. Slower forces can tear ligaments from the bone. Recently it has been shown that prolonged stretch of

ligaments (such as from prolonged slouching) can cause muscle spasms. It is important to have a proper seating set up and to change positions often. (6) Strained Muscles Muscle strains usually occur during activities that require the muscle to tighten forcefully. The muscle is strained either because it is not properly stretched, or warmed up, before the activity; it is too weak; or because the muscle is already injured and not allowed time to recover. Muscle strains can occur during exercise, sports activities and when lifting heavy objects. (6) There are other types of back injuries that can occur including disc degeneration. Please refer to OHCOW's "How Your Back Gets Injured: A Technical Guide to Preventing Injury" for more information. What are Work Related Musculoskeletal Disorders?

Work Related Musculoskeletal Disorders (WMSDs) is a term that defines injuries to muscles, tendons or nerves that are caused or aggravated by work. (4) These types of injuries are also commonly referred to as Repetitive Strain Disorders, Cumulative Trauma Disorders, Repetitive Stress Disorders and Work-related Upper Limb Disorders. (2) Some of the risk factors could include workplace organization such as intensified work load, stressful work environments with stressful deadlines, working in awkward postures for extended periods of time and repetitive loading or lifting. (4)

Rules for Safe Lifting Use the following acronym as a guide when engaging in client handling procedures: Back Straight Avoid Twisting Close to Body Keep Smooth Back Straight

Discs can tolerate larger compressive loads when the back is straight. Discs are weaker when lifting in a flexed position. Maintain the spine's neutral curves. Keeps spine aligned and moving smoothly. Minimizes stress on spine. Imaginary line to maintain curves in balance

Avoid Twisting

Discs are weaker when lifting is combined with twisting. Joints are designed to prevent rotation.

If you twist when you lift the joints become inflamed and sore.

Close to Your Body

If an object is at a greater distance from your body for lifting, your back muscles and joints have to work harder to lift the weight creating greater stress on your back. If you keep the exact same load close to your body, the lesser distance creates a lighter load and less stress on your back.

Keep Smooth

Jerking increases the load on the discs.

Some Other Things to Think About

Always consider the use of a mechanical aid. During client handling, use your leg and hip muscles and knee joints to lift. When lifting a client or object, tighten your abdominal and pelvic muscles and keep the client or object close to your body to prevent injury. Avoid reaching over your head to lift to prevent strain on joints located along your spine. Lift in stages if you need to. If the person or object slips, lower them gently to the floor while tightening your abdominal muscles and avoid rotation. Follow the general lifting guidelines recommended by the National Institute for Occupational Safety and Health (NIOSH) which states, the most a person can lift with minimal risk of injury under ideal conditions is 23 kg or 51 pounds.(7) Refer to NIOSH lifting fact sheet for more information.

What is a Minimal Lift Program?

A minimal lift program is a program that will help to reduce the unnecessary risk of injury for clients and staff through the reduction of manual lifting of clients. The goal of a minimal lift program is to provide employees with a policy that will promote an environment where the usage of assistive equipment is encouraged and expected. These goals can be achieved by providing staff with access to an appropriate number of assistive devices for patient handling. These could include: walking belts, total lifts, sit stand lifts, shower chairs, transfer boards and slide sheets. Training can involve policy implementation goals through hands on teaching/training program and practice sessions. (5)

*If your agency is interested knowing more about a Minimal Lift Program and Policies, we can help. Please refer to contact information at the end of this booklet. Defining Transfers, Lifts, and Repositioning

Transfers are guiding and/or assisting the patient from one surface to another. The patient is able to bear some weight in the legs and/or arms, and/or a part of the weight is borne by an assistive device such as a transfer board, walker or cane. Lifts are any procedure where the patient's entire body weight is borne by someone or something other than the patient (i.e.: a mechanical lifting device) for purposes of repositioning or moving to another surface. Repositioning is shifting, adjusting or changing the patient's position in bed, wheelchair, chair, or other supportive surface. (5)

Assessment: Completing an assessment before a transfer or lift is important because it:

Helps to determine risk for injury. Promotes continuity of care. Helps you to be prepared for possible risks. Helps to minimize the risk of injury for the health care worker and the client.

Assessment of the Work Area:

The work area should allow easy access to patients. A room should not be cluttered with furniture or equipment. A cluttered room increases the potential for trips and falls. A small room, such as a bathroom, may not allow natural body movements. Transfer patients onto a shower chair outside the bathroom to reduce transfers in crowded spaces. In small rooms, there may not be enough room for a portable lifting device. There are fixed lifting aids on tracks which do not require a lot of space. There should be enough clearance around beds and toilets to allow access on either side (at least 90 cm). A highly polished or wet floor does not provide good traction or a safe base for lifting (i.e. shower). Slips are more likely to occur on a highly polished or wet floor. Cover floors that get wet with a non-slip material.

Purchasing of Equipment:

Purchase furniture with patient handling in mind. Removable arm and foot rests on wheelchairs and shower chairs make transfers easier. Beds that can be raised or lowered also make transfers easier. Adaptive clothes are needed for patients who are toileted using the hoist. The shower and toilets should be designed so pushing and pulling shower chairs into position is as easy as possible (i.e. reduce height changes in the floor).


Ensure there are enough nurses and nursing assistants available to perform patient handling tasks safely especially during high activity periods.

Client Cognition:

Assess the client's senses, state of mind, memory, communication medical status and physical condition before engaging in client handling procedure.

Information about Transfers, Lifts and Repositioning The following logos provide recommended guidelines for patient handling. Independent Transfers:

This should be used when a client is able to mobilize without risk of injury and the client is comfortable with the use of mobility aids. (5)

Supervised Transfers:

This should be used when the client is able to mobilize, but may require verbal or minimal physical cueing. Transfer belts should be used in all cases. (5)

One-person Transfer Belt/ Pivot Transfer:

This should be used when a client can stand unsupported or weight bear with assistance of one person who will provide less than 40 pounds (18 kg) of assistance. (5) This transfer can also be performed if the physician orders feather, toe-touch or partial weight bearing. For safe handling a transfer belt must be used. (5)

Two-person Standing Pivot Transfer:

This transfer should be used when a client can bear weight through the legs but is heavy and unreliable. This technique requires two health care workers, with the tall person behind the patient. A transfer belt must be used. (5)

Walker Transfer:

Walker transfer should be used when a client can bear weight through at least one leg, and whose upper extremity strength and mobility are adequate. This can also be used if the physician orders feather, toe-touch, or partial weight bearing.(5)

Sit-Stand Mechanical Lift (SARA Lift):

This lifting technique should be used when a client can sit with minimal support at the edge of the bed and is able to bear some weight. The client may be cognitively

predictable and reliable. The client is able to tolerate harness under his/her arms. This should not be used with clients who have a hemiplegic arm. (5) Total Mechanical Lift:

A total mechanical lift should be used when a client can only minimally transfer or is not able to assist with weight bearing. This should also be used if the client is cognitively unreliable or uncooperative, has poor head control or sitting balance or is extremely large or heavy and requires assistance.(5)

Transfer Belt:

Transfer belts should be used when a client needs assistance with any transfer or for mobilization. (5)

Slide board/Transfer board:

Slide boards/Transfer boards should be used when transferring between equal height surfaces. Slide boards should also be used to facilitate transfer to wheelchair and for a client with excessive weakness in their lower limbs.(5)

Slide Sheets:

Slide sheets should be used in repositioning a client in bed who is unable to move themselves independently. Two caregivers are required for use. Slide sheets can also be used to move a client from bed to stretcher or in an emergency situation where the client has fallen in a confined space or the mechanical lift or other transfer methods cannot be employed. (5)


Examine your work environment. Avoid awkward or sustained postures or repetitive movements by varying your work activities throughout your day. Avoid forceful movements with a high load to avoid back injury. Maintain a neutral relaxed posture. Maintain client handling equipment. Ensure adequate staff to client ratios when considering engaging in client handling procedures. Ensure that staff has access to appropriate patient handling devices and ensure that all devices are in good working order. Ensure that your work area provides easy access to clients. (i.e. transfer patients onto a shower chair outside the bathroom to reduce transfers in crowded spaces). Plan ahead to ensure that you have considered all of the factors before engaging in a client-handling procedure. Adjust the working height of equipment to avoid bending stretching or twisting.

Consider the use of a mechanical aid for client transfers. Exercise such as strength and conditioning helps maintain functional ability and helps prevent muscle sprains, low back pain, osteoarthritis, osteoporosis, shoulder instability and knee stability and pain. Stretching should be incorporated into an exercise program to help improve flexibility. Do not lift anything immediately after sitting for an extended period of time. Walk around and loosen up.

Bottom Line:

Reducing the chance of injury when handling patients requires a combination of equipment, training, and policy. If staff members are not properly trained on how and when to use ergonomic equipment, they will not use it. Health care workers should be involved in selecting equipment and creating policies since they are the patient handlers. For more information on equipment, handling techniques, and policies, read the booklets listed in the "Additional Resources" or contact the nearest OHCOW.

1. Akyeampong, E., & Uscalcas, J. (1998). Work Absence Rates, 1980 to 1997. Statistics Canada, Catalogue no.71-535-MPB, no. 9 2. Hagen, K., & Thune, O. (1998). Work incapacity from low back pain in the general population. Spine, 23, 2091-2095. 3. Kerr, M., Laschinger, H., Severin, C., Almost, J., Thomson, D., O'Brien-Pallas, L., Shamien, J., McPerson, D., Koehoorn, M., & LeClair, S. (2002). Monitoring the Health of Nurses in Canada. Ottawa: Canadian Health Services Research Foundation. 4. Institute for Work& Health (2005), IWH fact sheet work-related musculoskeletal disorders. 5. Health Care Health and Safety Association (2003). HCHSA Handle with Care: A Comprehensive Approach to Developing and Implementing a Client Handling Program. 6. McGill, S Low back disorders : evidence-based prevention and rehabilitation. Champaign, IL, Human Kinetics; 2002. 7. Waters, T., Puts Anderson, V., Garg, A. & Fine, L. (1993). Revised NIOSH equation for the design and evaluation of Manual lifting tasks. Ergonomics, 36(7), 749-776. Additional OHCOW Resource Booklets: 1. Work-related Musculoskeletal Disorders. 2. Working on Your Feet. 3. Franklin Gothic BookOblique