Common Errors in healthcare
- Medications- nurse is the last line of defense
- FallsSurgery- wrong site
- Diagnostic inaccuracy- wrong treatment
- Equipment failure- IV pump
- Transfusion error- blood type, wrong patient
- Laboratory- incorrect labeling
- System failure- no independent double check
- Environment- clean up spills
- Communication-why is documentation important?
What can you do to promote pt safetly.
- What can you do to promote safety for the patient?
- -Assessment: assess living environment and the ability of the family to make good judgements for the pt.
- -Is the family important?
- -List some interventionsAlways remember ABC –AirwayBreathingCirculation
If a pt falls...
- Always assess for injuries 1st. Don't try to pick them up right away.
- If pt has a Hx of falls, assess what the issue is in order to determin fall risk.
- In CO, yellow tag typically indicates fall risk. Also a leave-shaped tag on a door--same thing.
How do you reduce risk of falls?
- Identify risk
- Call light within pts reach
- non-skid booties.
- Bedrails up. Can have up to 3 raised at 1 time.
- Bed alarm-->klaxon to alert nursing staff that pt has gotten up.
- Keep room clear of clutter. Pay special attention to trash can placement.
- Lower bed.
- Education staff
- Education pts and support (family)
- Proper communication/documentation
What to do after the fall...
- Focused Assessment
- Notify LIP (Licensed Independent Practitioner)
- Document: remember to state what you saw and what was reported by someone else and to document the difference.
- Occurrence report-->not part of the pt's med record, but risk assessment team who will use it to assess liability and hospital safety.
What does RACE and PASS stand for in ration to hospital/facility fires.
- R. A. C. E. (R) – remember this for the hospital and other encounters
- Relocate (may be added)
- P. A. S. S. – Pull, Aim, Squeeze, Sweep
- Find the guidelines at each facility...
Disaster plans. (read in book and ATI)
- Disaster plans are in place in the community and in the facilities
- Know where the guidelines are, and know your role within the facility.
- Know who to call
- What are your resources?
- --As a healthcare professional
- --As a studentAs a consumer
- A restraint is defined as any method of physically restricting a person’s freedom of movement, physical, activity, or normal access to his or her body.
- Do you agree with this definition?
- Always use least restrictive method. Most common are wrist restraints, and always use as last resort.
- Poze-tie to bed frame but cause most restraint-related deaths when they struggle-->hang themselves.
- Try diversions/entertainment before going to restraints. Try to keep'em busy.
- If all else fails, must call Dr. to get order for restraints unless you feel your safety is in jeopardy. In that case must get the order in a timely matter.
Restraints can be behavioral and non-behavioral.
- Physical and chemical.
- Must be removed and reassessed q 2hrs.
- Must also do a trial "release."
- q 15min someone has to assess pt for food/water/elimination, etc.
- Make sure physical restraints are not on boney prominences. Two fingers between restraint and limb.
- Document, document DOCUMENT.
Common hazards for healthcare workers
- Back injury
- Needlestick injury
- Radiation injury
- Workplace violence
- --Body mechanics
- --Sharps awareness, proper disposal
- --Radiation precautions
- --Environmental awareness of personal safety
Obstacles to a safe system...
- a complex and risk-prone system that can produce unintended consequences
- lack of comprehensive verbal, written, and electronic communication systems
- tolerance of stylistic practices and lack of standardization
- fear of punishment inhibiting reporting and lack of ownership for patient safety
- Culture of facility
- Limited short term memory. WRITE IT DOWN!
Joint commission goals 2011-2012
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