Safety COnsiderations
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Rowan College, Burlington County *
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Medicine
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Apr 3, 2024
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Safety Considerations in the Provision of Client Care
1.
Creating a Culture of Safety
a.
The Institute of Medicine (now the National Academy of Medicine) has led multiple initiatives to decrease concerns related specifically to medical errors that can result in illness, injury, or even death in the hospitalized client. The IOM first published its report, To Err Is Human: Building a Safer Health System,” in 1999 to bring attention to health care industry safety systems related to the prevention and control of errors. This publication highlighted the point that creating a culture of safety needs to be a priority to decrease unexpected deaths of clients, HAIs, surgical complications, and nurse turnover and burnout, as well as to improve clients’ satisfaction with the care they receive. Health care facilities that have implemented effective culture of safety environments value open and honest communication with frontline workers, have policies for confidential reporting of safety issues, and report both actual safety-related incidents and near misses. i.
Nursing is Key
ii.
Environments that value open honest communication and have policies in place to report safety related incidents
iii.
Examples
1.
Hourly rounding
2.
Rapid response teams (RRT)
3.
I-SBARR communication
b.
Nurses have a key role in creating a culture of safety for the hospitalized client. Nurses are the members of the health care team who have the most contact with clients throughout their hospitalization. Research has shown a direct correlation between nurses’ work environment and client safety. Nurse staffing levels, availability of nursing resources, and management responsiveness to nurses’ concerns are all factors that health care facilities must address.
The culture of safety is important not only for the prevention and control of medical errors, but also for minimizing operational breakdowns that can lead to errors. In summary, there is a correlation between the safety culture, the nurse’s work environment, and the organizational role.
c.
One initiative undertaken by the Institute for Healthcare and the Robert
Wood Johnson Foundation to change the hospital environment sought to redesign bedside care for clients. The Transforming Care at the Bedside plan includes the following components:
i.
Have nurses spend 70% of their time at the bedside performing direct client care ii.
Strengthen management through leadership development programs iii.
Implement a rapid response team for the facility’s medical–
surgical units iv.
Create frameworks for standardized communication d.
According to a study by Landro, nurses often spend less than 2 hours of a 12-hour shift at the client’s bedside providing direct client care. It has also been shown that the more time nurses spend at the bedside, the less likely clients are to have untoward outcomes such as falls, HAIs, and medication errors. Therefore, organizations need to encourage nurses to develop evidence-based strategies that can assist
them in being able to be at the clients’ bedside giving direct care, and that will ultimately improve client safety and satisfaction. Among the changes in traditional work practices that have been implemented to assist nurses in increasing their time with clients at the bedside are the
following:
i.
When nurses conduct hourly rounding, a member of the nursing staff checks on clients every hour to proactively address their needs such as toileting, positioning, pain management, and safety checks of siderail and bed position or proximity of the call
light to the client. In units where nurses spend more time at the bedside more through implementation of hourly rounding, data show decreased fall rates for clients. ii.
Handoff communication occurs at the client’s bedside. e.
In addition, nursing management may lack the leadership skills, knowledge, and direction needed to support nurses in improving client care. Thus, the second component of the Transforming Care at the Bedside plan is a recommendation that nurse leaders go through a leadership development program to develop strong management skills and strategies. They also need these skills: i.
Team performance building strategies ii.
The ability to hire staff iii.
A willingness to uplift and praise staff when needed, as well as coach them when they lack a skill or behavior iv.
The ability to conduct performance evaluations of staff members
f.
The third component of the Transforming Care at the Bedside plan is the development of a rapid response team (RRT). The RRT is a dedicated interdisciplinary group whose responsibility is to proactively
bring their critical care knowledge and skills to the client’s bedside. This team usually consists of an ICU nurse, respiratory therapy provider, and a critical care provider. Team members receive a priority alert when a client is not doing well or a client’s condition changes suddenly. When it receives an alert, the RRT gathers at the client’s bedside to rescue the client from a potentially life-threatening event (e.g., cardiac arrest). g.
Each facility should have a policy about who is on the RRT, when the RRT should be notified, and how to notify the RRT. It is important to review the facility’s policy to avoid a delay in the RRT arriving to the client’s bedside. Conditions that may warrant a callout of the RRT may include the following: i.
A sudden change in vital signs
ii.
Low oxygen saturation despite efforts to oxygenate iii.
Chest pain despite the administration of nitroglycerine iv.
Seizure v.
Medical professional has a deep concern about the client’s condition vi.
Sudden variation in the client’s mental status h.
The fourth component of the Transforming Care at the Bedside plan is to utilize a standardized communication tool. ISBARR (identity, situation, background, assessment, recommendation and read back) is one such tool that aids in nurse-to-nurse or nurse-to-provider communication. Health care facilities that use RRTs and the ISBARR tool to communicate have shown improved client outcomes, improved nurse satisfaction and retention, increased nursing time spent at the bedside, and lower hospital-associated costs. i.
ISBARR Communication Tool
1.
ISBARR is used as a report or handoff guide to convey relevant client-specific information to other medical professionals.
a.
Identity: Introduce yourself and where you are calling from. b.
Situation: Client name and age, admitting diagnosis, and chief complaint or urgent need for the rapid response to be called. c.
Background: Medical history including current medications and advanced directives (if any).
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d.
Assessment: General client impression and significant findings through assessment, diagnostic tests, lab work, and vital signs. e.
Recommendations: Treatment provided and the client’s response to the treatment. f.
Read back: Read back the message or prescription from the provider, which allows for clarification of any
2.
Types of Unexpected Events
a.
Nurses must understand what qualifies as adverse health care–related events, including how they differ from near misses, client safety events, and sentinel events: (all will be recorded)
i.
A near miss is a potential error or event or circumstance that could have caused harm, but that was caught and avoided. ii.
A client safety event is an unexpected event or circumstance that occurred with or without injury to the client, but that had the potential to cause harm to the client . iii.
An adverse event is a situation or circumstance that caused unexpected harm to the client. iv.
A sentinel event (never event) is a critical, unexpected adverse event that caused severe physical or psychological harm to a client, including death, dismemberment, permanent injury, and severe or temporary injury. b.
Note that expected occurrences related to a client’s illness, such as death, are not sentinel events. Examples of sentinel events include surgical and postsurgical errors and complications, client suicide, infant
abduction, and falls with serious injury. The most common sentinel events in the United States include performing a surgical procedure on the wrong body part, complications of surgery or during surgery or postoperatively, and clients committing suicide within the facility .
3.
Occurrence Reporting
a.
A safe culture for both the client and the health care team member is promoted when adverse events, sentinel events, client safety events, and near misses are reported. An occurrence (incident) report is not meant to punish the individuals involved, but instead to track the near miss or events so that measures can be taken to prevent future occurrences from happening. All client safety and care events or concerns must immediately be presented to the nurse leader or another manager according to the facility’s reporting procedures and policies. Once the leadership and the provider are notified and the
client is safe, then an occurrence report or incident report should be made. Occurrence reporting is intended to provide the hospital, administration, and staff with an opportunity to investigate the issues that led up to the unexpected event, with the information obtained then being used to help prevent future unexpected incidents. These reports generally come from frontline staff members (e.g., nurses, pharmacists, and physicians), although they can originate from management as well. An occurrence report should not be mentioned in
the client’s hospital chart, but rather is an internal report for the facility
only. However, it may be used for legal purposes in the future.
i.
Check patient, notify provider/supervisor, then file report
ii.
Not for punishment or client record
iii.
Used to track event to prevent it from happening again
b.
Risk management and leadership generally prefer that occurrence reports identify the persons involved in the event, witnesses to the event, and the problems or systems that led up to the incident, as well as the outcome. In response to the occurrence report, action plans can be created to help prevent future occurrences. Following are some examples of unexpected events that must be documented in an occurrence report: i.
Accident or injury of a client, staff member, or a visitor (e.g., a fall) ii.
Unexpected vaccine reaction iii.
Unexpected drug reaction iv.
Administration of the wrong vaccine or drug to a client
v.
Incorrect administration of a drug or vaccine to a client vi.
Property damage or lost items vii.
Exposure to blood, body fluid, or other infectious material on the
skin, eyes, or mucous membranes
viii.
Atypical behaviors, actions, and events that go against the facility’s policy or procedures; client injury may occur as a result 4.
Safety Assessment a.
Client and staff safety is of the utmost importance in all health care facilities and is regulated through accrediting agencies such as TJC and
the Magnet recognition program; through governmental agencies such as the Centers for Medicare and Medicaid Services (CMS), the Occupational Safety and Health Administration (OSHA), and the State Health Department; state boards of nursing; and local agencies such as
the fire department and city code inspectors. All these entities work in collaboration with health care facilities to ensure that they are complying with client and staff safety requirements. All employees of a
health care facility should receive training first during orientation, and then annually, regarding the facility’s policies on environmental hazards that can cause harm to clients and staff. b.
Proper verification of client information as well as effective communication can help prevent many errors that affect client safety. Based on the findings from several extensive research projects, the Agency for Healthcare Research and Quality created a list of 10 evidence-based recommendations for facilities to implement with the goal of improving client safety. i.
1. Prevent infections. ii.
2. Simplify discharge instructions. iii.
3. Establish a protocol to prevent hospital-acquired venous thromboembolism (VTE). iv.
4. Improve education provided to clients regarding medications. v.
5. Limit the amount of continuous time for which a health care provider can provide direct client care. vi.
6. Work with a patient safety organization (PSO) to identify potential risks to client safety.
vii.
7. Improve design aspects of the facility that support client safety.
viii.
8. Survey facility personnel to assess the culture of safety. ix.
9. Create better teams to facilitate communication and improve response times. x.
10. Use an evidence-based protocol when performing invasive client procedures. c.
One of AHRQ’s 10 tips is just as important for providers’ safety as it is for clients’ care—namely, the recommendation to reduce work hours for providers so that they have adequate time for sleep between shifts.
Fatigue has been shown to increase errors and injuries among nurses. In addition to the risks to the nurse’s health and fatigue-related client safety issues, lack of sleep can adversely affect the general public. In a
2018 position statement, the American Academy of Nursing on Policy acknowledged that when nurses have less than 4 hours of sleep within a 24-hour period, their risk of a motor vehicle accident increases 11.5 times, whereas if nurses have at least 6 hours of sleep, that risk increases only 1.3 times.
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d.
Awareness of client safety issues is paramount for nurses. Primary considerations include fall assessment and the use of safe practices including, but not limited to, using siderails for beds as indicated; following the rights of medication administration; awareness of client allergies; proper use of restraints; prevention of pressure injuries; and appropriate use of aseptic technique to reduce the risk of infections. Nurses also need awareness of safety concerns that can affect them as
users of medical equipment and products (including proper handling of
sharps), as well as knowledge about potential exposures to bloodborne
pathogens and other infectious diseases. Nurses can minimize physical
injuries to themselves by using proper body mechanics. Knowledge of fire, chemical, and radiation safety is also important for nurses and is discussed later in this lesson. 5.
Client Identification
a.
As mentioned earlier, client identification is an integral aspect of client safety. Misidentification of clients can result in wrong-site surgeries, incorrect procedures, and other errors, including medication and blood transfusion oversights. Consistent client identification must occur prior to all treatments, with the client self-identifying to the provider(s), if possible. The nurse is responsible for verifying client identity through a minimum of two specific identifiers, such as the client’s name, date of birth, or medical record number. The client’s room number should not be used as an identifier, since it can change or be incorrect. In some cases, more than one client with the same name may be admitted to the same facility. In these instances, the nurse should follow the facility’s policy for same-name alerts and utilize additional information to identify the client. Options for additional verifying information include the client’s Social Security number, address, phone number, or photo. b.
The Joint Commission has identified several ways that incorrect client information and identification can occur despite the use of electronic technology created to prevent such errors. Risks include having multiple client records open simultaneously, which could lead to documenting in the wrong record or prescribing tests or medications for the wrong client. Identification errors can result from nurse fatigue or poor time management, electronic medical record (EMR) malfunctions, and communication issues, especially when computers malfunction . To reduce the risk of client identification errors, TJC recommends standardizing the identification process, documenting in a
timely manner, utilizing the client’s photo in the EMR, asking the client to verbalize identification information, and avoiding the use of nonspecific aliases, especially for newborns (e.g., “baby girl”).