SAFETY

INTRODUCTION
• A fundamental concern of nurses, which extends from the bedside to
the home to the community, is preventing injuries and assisting the
injured. Motor vehicle crashes, falls, drowning, fire and burns,
poisoning, inhalation and ingestion of foreign objects, and firearm use
are major causes of injury and death.
• Nurses need to be aware of what constitutes a safe environment for a
particular person or for a group of people in home and community
settings. Injuries are often caused by human conduct and can be
prevented.
FACTORS AFFECTING SAFETY
FACTORS AFFECTING SAFETY
• Age and Development
• Through knowledge and accurate assessment of the environment,
people learn to protect themselves from many injuries. Children
walking to school learn to stop before crossing the street and wait for
oncoming traffic. They also learn not to touch a hot stove. For the
very young, learning about the environment is essential. Only through
knowledge and experience do children learn what is potentially
harmful.
FACTORS AFFECTING SAFETY
• Lifestyle
• Lifestyle factors that place people at risk for injury include unsafe
work environments; residence in neighborhoods with high crime
rates; access to firearms; insufficient income to purchase safety
equipment or make necessary repairs; and access to illicit drugs,
which may also be contaminated by harmful additives. Risk-taking
behaviors are contributing factors in some accidents.
FACTORS AFFECTING SAFETY
• Mobility and Health Status
• Alterations in mobility related to paralysis, muscle weakness,
diminished balance, and lack of coordination place clients at risk for
injury. Spinal cord injuries or paralysis impair the client’s ability to
perceive discomfort, increasing the risk for injury or skin breakdown.
Clients who have impaired mobility such as hemiplegia or leg casts
are prone to falls related to poor balance. Clients weakened by illness
or surgery may suffer from impaired levels of alertness, placing them
at risk for falls or injury.
FACTORS AFFECTING SAFETY
• Sensory-Perceptual Alterations
• Accurate sensory perception of environmental stimuli is vital to
safety. People with impaired touch perception, hearing, taste, smell,
and vision are highly susceptible to injury. A person with impaired
vision may trip over a toy or not see an electric cord. A person with
impaired hearing may not hear a siren in traffic. A person with
impaired olfactory sense may not smell burning food or the sulfur
aroma of escaping gas.
FACTORS AFFECTING SAFETY
• Cognitive Awareness
• Awareness is the ability to perceive environmental stimuli and body
reactions and to respond appropriately through thought and action.
Clients with impaired awareness include people lacking sleep; people
who are unconscious or semiconscious; disoriented people who may
not understand where they are or what to do to help themselves;
people who perceive stimuli that do not exist; and people whose
judgment is altered by disease or medications, such as narcotics,
tranquilizers, hypnotics, and sedatives. Mildly confused clients may
momentarily forget where they are, wander from their rooms,
misplace personal belongings, and so forth.
FACTORS AFFECTING SAFETY
• Emotional State
• Extreme emotional states can alter the ability to perceive
environmental hazards. Stressful situations can reduce a person’s
level of concentration, cause errors of judgment, and decrease
awareness of external stimuli. People with depression may think and
react to environmental stimuli more slowly than usual.
FACTORS AFFECTING SAFETY
• Ability to Communicate
• Individuals with diminished ability to receive and convey information
are at risk for injury. They include clients with aphasia, language
barriers, or the ability to read. For example, the person unable to
interpret the sign “No smoking—oxygen in use” could cause a fire.
FACTORS AFFECTING SAFETY
• Safety Awareness
• Information is crucial to safety. Clients in unfamiliar environments
frequently need specific safety information. Lack of knowledge about
unfamiliar equipment, such as oxygen tanks, intravenous tubing, and
hot packs, is a potential hazard. Healthy clients need information
about water safety, car safety, fire prevention, ways to prevent the
ingestion of harmful substances, and many preventive measures
related to specific age-related hazards.
FACTORS AFFECTING SAFETY
• Environmental Factors
• Client safety is affected by the health care setting. Depending on the
client situation, the nurse may need to assess the environment of the
home, workplace, or community. Bioterrorism and natural disasters
are national safety concerns.
HEALTH CARE SETTING
HEALTH CARE SETTING
• In 1999, the Institute of Medicine (IOM) released its first publication on client
safety and medical errors: To Err Is Human: Building a Safer Health System. This
landmark report attracted a great deal of attention when it reported that 98,000
people died in hospitals each year as a result of medical errors, and many more
were seriously harmed (Regenstein, 2013). Since this report, organizations such
as The Joint Commission and the Agency for Healthcare Research and Quality
(AHRQ) developed and/or continued to accelerate work around patient safety. In
addition, the Quality and Safety Education for Nurses (QSEN) project developed
guidelines that would enable future nurses to have the knowledge, skills, and
attitudes necessary to improve the quality and safety of the health care systems
within which they work (Sammer & James, 2011). However, it is now more than a
decade later and preventable errors continue. For example, Barclay (2013) states
that “diagnostic errors result in between 44,000 and 80,000 annual deaths in the
United States alone, and bed sores lead to another 68,000 deaths. Thousands
more die each year as a result of communication errors or failure to receive
evidence-based interventions (para. 3).”
HEALTH CARE SETTING
• WORKPLACE
• In the workplace, machinery, industrial belts and pulleys, and chemicals may create
danger. Worker fatigue, noise and air pollution, or working at great heights or in
subterranean areas may also create occupational hazards. The work environment of the
nurse may also be unsafe. The U.S. Bureau of Labor Statistics (2012) reports that nursing
has many hazards. Some of the hazards identified were exposure to infectious agents;
activities in client care that require lifting, bending, and walking; exposure to hazardous
compounds; and needlesticks. Nurses must adhere to standardized guidelines to prevent
injury or disease.
• HOME
• A safe home requires well-maintained flooring and carpets, a nonskid bathtub or shower
surface, handrails, functioning smoke alarms that are strategically placed, and knowledge
of fire escape routes. Outdoor areas, where steps or stairs increase the risk for falls, may
need ramps instead. Swimming pools need to be safely secured and maintained.
Adequate lighting, both inside and out, will minimize the potential for accidents.
HEALTH CARE SETTING
• COMMUNITY
• Adequate street lighting, safe water and sewage treatment, and regulation
of sanitation in food buying and handling all contribute to a healthy,
hazard-free community. A safe and secure community strives to be free of
excess noise, crime, traffic congestion, dilapidated housing, or unprotected
creeks and landfills.
• BIOTERRORISM
• The Centers for Disease Control and Prevention (CDC) (n.d.) defines a
bioterrorism attack as the “deliberate release of viruses, bacteria, or other
germs (agents) used to cause illness or death in people, animals, or plants
(para. 1).” Bioterrorism agents are separated into three categories,
depending on how easily they can be spread and the severity of illness or
death they cause.
HEALTH CARE SETTING
• Category A agents have the highest risk because they:
• • Can be easily spread or transmitted from person to person.
• • Result in high death rates and have the potential for major public health impact.
• • Might cause public panic and social disruption.
• • Require special action for public health preparedness.
• Category B agents are the second highest priority because they:
• • Are moderately easy to spread.
• • Result in moderate illness rates and low death rates.
• • Require specific enhancements of CDC’s laboratory capacity and enhanced disease monitoring.
• Category C agents include emerging pathogens that could be engineered for mass spread in the future
because they:
• • Are easily available.
• • Are easily produced and spread.
• • Have the potential for high morbidity and mortality rates and major health impact.
HEALTH CARE SETTING
• DISASTER PLANNING
• Nursing personnel play a key role in disaster management and client
care throughout all aspects of the health care industry. Nurses are
employed in acute care facilities, ambulatory care facilities, longterm
care facilities, and within community agencies, including home care
and public health. The terrorist events of September 11, 2001, and
natural disasters such as Hurricane Sandy in 2012 provided the United
States with evidence that nursing and health care must address
disaster planning head on.
NURSING MANAGEMENT
NURSING MANAGEMENT
• Assessing
• Assessing clients at risk for injury involves (a) noting pertinent
indicators in the nursing history and physical examination, (b) using
specifically developed risk assessment tools, and (c) evaluating the
client’s home environment.
NURSING MANAGEMENT
• Nursing History and Physical Examination
• The nursing history and physical examination can reveal considerable
data about the client’s safety practices and risks for injury. Data
include age and developmental level; general health status; mobility
status; presence or absence of physiological or perceptual deficits
such as olfactory, visual, tactile, taste, or other sensory impairments;
altered thought processes or other impaired cognitive or emotional
capabilities; substance abuse; any indications of abuse or neglect; and
an accident and injury history. A safety history also needs to include
the client’s awareness of hazards, knowledge of safety precautions
both at home and at work, and any perceived threats to safety.
NURSING MANAGEMENT
• Risk Assessment Tools
• Risk assessment tools are available to determine clients at risk both for
specific types of injury, such as falls, or for the general safety of the home
and health care setting. In general, these tools direct the nurse to appraise
the factors affecting safety as previously discussed. The tools summarize
specific data contained in the client’s nursing history and physical
examination. Client risk factors and environmental hazards for falls are
discussed later in this chapter (see the Falls section).
• Home Hazard Appraisal
• Hazards in the home are major causes of falls, fire, poisoning, suffocation,
and other accidents, such as those caused by improper use of household
equipment, tools, and cooking utensils. See Chapter 8 for a summary of
specific data necessary for a home hazard appraisal.
NURSING MANAGEMENT
• National Patient Safety Goals
• As a result of IOM’s report To Err Is Human (2000), the health care industry and national
organizations (e.g., National Patient Safety Foundation) increased their awareness of the
need to improve client safety. For example, since 2002, The Joint Commission has
required its accredited agencies to meet specific National Patient Safety Goals (NPSGs).
The newest goal is to reduce the harm associated with clinical alarm systems. Davis,
Lockhart, Landon, and Henry (2014) report that 80 clients died and 13 were severely
injured in U.S. hospitals between January 2009 and June 2012 as a result of alarm-related
problems (p. 40). There is a high risk of injury if alarms are silenced, turned off, or
ignored. Alarms should be checked at the beginning of each shift to ensure that they are
functional. See Box 32–2 for The Joint Commission’s 2014 National Patient Safety Goals.
It is important to remember that the focus of the NPSGs is on system-wide solutions.
This is an important change from the traditional method of finding out who made the
error (e.g., creating an environment of fear and scapegoating) to analyzing the system to
find out why the error was made (e.g., creating an environment of learning and
improvement).
NURSING MANAGEMENT
• Bioterrorism Attacks
• Nurses are considered frontline health care providers. As a result,
they need education and training to be able to assess and detect
potential bioterrorism attacks. The biologic agents that have been
identified by the CDC as being of highest concern include anthrax,
botulism, plague, viral hemorrhagic fevers, smallpox, and tularemia.
NURSING MANAGEMENT
• Diagnosing
• Under the domain of Safety/Protection, NANDA International offers a
broad diagnostic label related to safety issues: • Risk for Injury:
Vulnerable to physical damage due to environmental conditions
interacting with the individual’s adaptive and defensive resources,
which may compromise health (Herdman & Kamitsuru, 2014, p. 386).
NURSING MANAGEMENT
• Planning
• When planning care to prevent accidents and injury, the nurse
considers all factors affecting the client’s safety, specifies desired
outcomes, and selects nursing activities to meet these outcomes. The
major goal for clients with safety risks is to prevent accidents and
injury. To meet this goal, clients often need to change their health
behaviors and may need to modify the environment.
NURSING MANAGEMENT
• Planning
• Desired outcomes associated with preventing injury depend on the
individual client. Examples of desired outcomes, although established in
the planning phase, are provided in the Evaluating section on page 666.
• Nursing interventions to meet desired outcomes are largely directed
toward helping the client and family to accomplish the following:
• • Identify environmental hazards in the home and community.
• • Demonstrate safety practices appropriate to the home health care
agency, community, and workplace.
• • Experience a decrease in the frequency or severity of injury.
• • Demonstrate safe child-rearing practices or lifestyle practices.
NURSING MANAGEMENT
• Implementing
• Hazards to safety occur at all ages and vary according to the age and development level of the
individual.
• Promoting Safety Across the Life
• Span Measures to ensure the safety of people of all ages focus on (a) observation or prediction of
potentially harmful situations so that harm can be avoided and (b) client education that
empowers clients to protect themselves and their families from injury. Safety measures covering
the life span from infancy to older adults are listed in the accompanying Client Teaching.
• Newborns and Infants Accidents are a leading cause of death during infancy, especially during the
first year of life. Infants are completely dependent on others for care; they are oblivious to such
dangers as falling or ingesting harmful substances. Parents need to learn the amount of
observation necessary to maintain infant safety. They also need help to identify and remove
common hazards in and around the home, and first-aid information that includes
cardiopulmonary resuscitation and interventions for airway obstruction. Common accidents
during infancy include burns, suffocation or choking, automobile crashes, falls, and poisoning.
Education and support of parents can make them more knowledgeable and better prepared to
protect their children from accidents and injuries.
NURSING MANAGEMENT
• Toddlers Toddlers are curious and like to feel and taste everything. They are fascinated by
potential dangers, such as pools and busy streets, so they need constant supervision and
protection. Parents prevent many accidents by “toddler-proofing” the home or other setting
where the child will be (Figure 32–2 •). This practice extends to the use of federally approved car
restraints and removing or securing all items that can pose a safety hazard to the child in any
setting. It may be necessary to inspect for and remove sources of lead from the environment.
Lead poisoning (plumbism) is a risk for children exposed to lead paint chips, fumes from leaded
gasoline, or any “leaded” substances.
• Preschoolers Children of preschool age are active and often very clumsy, making them
susceptible to injury. Control of the environment must continue, keeping hazards such as
matches, medicines, and other potential poisons out of reach. Safety education for the child must
begin now. Education of the preschooler involves learning how to cross streets, what traffic
signals mean, and how to ride bicycles and other wheeled toys safely. Caution children to avoid
hazards, such as busy streets, swimming pools, and other potentially dangerous areas. Parents
must maintain careful surveillance; the developmental level of the preschooler does not allow for
self-reliance in matters of safety. Parents must also keep in mind that their child’s cognitive and
motor skills increase quickly; hence, safety measures must keep up with the acquisition of new
skills.
NURSING MANAGEMENT
• School-Age Children By the time children attend school, they are learning to
think before they act. They often prefer adult equipment to toys. They want to
play with other children in such activities as bicycling, hiking, swimming, and
boating. Although sensitive to peer pressure, the school-age child will respond to
rules. Children of this age engage in fantasy and magical thinking. They often
imitate the actions of parents and superheroes with whom they identify.
• Adolescents Obtaining a driver’s license is an important event in the life of an
adolescent in the United States, but the privilege is not always wisely handled.
Teenagers may use driving as an outlet for stress, as a way to assert
independence, or as a way to impress peers. When setting limits on automobile
use, parents need to assess the teenager’s level of responsibility, common sense,
and ability to resist peer pressure. The age of the teenager alone does not
determine readiness to handle this responsibility.
NURSING MANAGEMENT
• Young Adults Motor vehicle crashes are by far the leading cause of
mortality for this group; other causes of death for young adults
include drowning, fires, burns, and firearms.
• Middle-Aged Adults Changing physiological factors, as well as
concern over personal and work-related responsibilities, may
contribute to the injury rate of middle-aged people. Motor vehicle
crashes are the most common cause of accidental death in this age
group. Decreased reaction times and visual acuity may make the
middle-aged adult prone to accidents. Other unintentional causes of
death for middle-aged adults include falls, fires, burns, poisonings,
and drownings. Occupational injuries continue to be a significant
safety hazard during the middle years.
NURSING MANAGEMENT
• Older Adults Injury prevention is a major concern for older adults.
Because vision is limited, reflexes are slowed, and bones are brittle,
activities such as climbing stairs, driving a car, and even walking
require caution. Driving, particularly at night, requires caution
because accommodation of the eye to light is impaired and peripheral
vision is diminished. Older adults need to learn to turn their head
before changing lanes and should not rely on side vision, for example,
when crossing a street or changing lanes. Driving in fog or other
hazardous conditions should be avoided.
•