Safety Flashcards
Sentinel event
Unexpected occurrence/risk of:
Death or serious physical/psychological injury.
Never events
Surgery on wrong person/body part.
Leaving a foreign body (scissors/gauze) inside after a surgery.
D/c infant to wrong parents.
RCA + when to do it for falls
Asking many “why”s to discover where improvements can be made.
Used after a fall that causes injury/death.
Restraint characteristics
Chemical or physical devices that can’t be easily removed.
Must be ordered from provider.
Must keep patient or others from harm.
NOT interfere w/physiological function (must check extremity often for skin injury or circulation).
LAST RESORT
Restraint examples
Side rails.
Geriatric chairs with attached trays.
Appliances tied at wrist/ankle/waist.
Infant mummy restraint.
Risks of restraints
Falls (w/injury)
Skin breakdown
Contractures (shortening/hardening of tissues)
Incontinence
Depression, delirium, anxiety
Aspiration & resp difficulties
Death (sentinel event)
Initial & ongoing restraint documentation
I: date/time, type of restraint, tried alternatives & their results, notification of family and provider.
O: freq of assessment (every 1-2hrs) & findings, release intervals, interventions like offered hydration/toileting/ROM
What is the 1st thing to assess right after a patient falls?
Any loss of consciousness
Falls: some modifiable risk factors
Wet floor, long chords, rug, bad lighting
Are incident reports mentioned in EHR chart?
Never
What is documented with falls?
History of falls
Use of assissted devices/lift equipment
Modifiable risk factors
Fall risk tool
Precautions used to prevent falls
Injury?
Fall precautions
Fall bundle: yellow non-skid socks, door sign, (armband/bed alarm)
Bed/chair alarms.
Fall contract.
Signs/posters.
Tools: gait belt, walker, wheelchair
PPE & examples for contact transmission
Gloves
Gown
C-diff, MRSA, infected wound
PPE & examples for droplet transmission
Mask
Meningitis, Influenza (anything else w/ a cough)
PPE & examples for airborne transmission
N95 mask
Negative pressure room
MTV: measles, TB, varicella