Other Safety Measures for Clients

Medical errors (Breaches in standards or failure to perform by a health care

provider that yields an unfavorable health result for a client.) have serious
consequences in health care settings. "Actions to improve the culture of safety
within health care is an essential component of preventing or reducing errors and
improving overall health care quality" (ARHQ, 2017).

To improve health outcomes for clients, nurses should:

 Assess, identify and document/communicate allergies, including latex sensitivity

and latex allergies.
 Implement seizure precautions based on policy/protocol.
 Ensure proper identification of client is used before providing care:
o Use two identifiers prior to administering a medication; asking a client to state his
or her full name and birthdate are common identifiers.
o Use client wristband and barcode identification technology in conjunction with an
electronic health record.
 Verify appropriateness and/or accuracy of treatment orders.

Chain of Infection

The incubation period is the time between entrance of the pathogen and the first
symptoms. If the host's defenses are successful, an infection may disappear
without progressing to the next stage.
Examples of incubation periods for specific diseases:

 Mumps: 18 days
 Varicella (chickenpox): 2 to 3 weeks
  Prodromal Stage

 Not all diseases have prodromal periods. For those that do, the prodromal
stage is the time from onset of nonspecific findings, such as fatigue and
malaise, to disease-specific findings. This is when the pathogen is multiplying
and the host is most contagious.

 Invasive Phase

During the invasive phase, the person exhibits the specific findings of the disease:

 Mumps: swelling of the parotid gland

 Common cold: sore throat, congestion

If the host cannot fight off an infection, such as pneumonia, influenza or a urinary
tract infection (UTI), the invasive phase can progress to systemic complications
such as septicemia and even death. Other diseases, such as varicella (chickenpox)
virus can reactivate years later, causing shingles.
Many of the preventable childhood diseases can cause (irreversible) complications:

 Mumps: Can cause sterility

 Measles: Can lead to pneumonia, encephalitis and permanent hearing loss
 Polio: Can lead to temporary or permanent muscle paralysis, disability and
deformities

 Convalescence

Convalescence is when the acute findings begin to disappear and the body returns
to normal health.

HAI & CAI

Health care-associated infections (HAI) are associated with devices or procedures
used to treat clients. HAIs are the most frequent adverse event in health care
delivery worldwide, leading to significant mortality as well as financial losses for
health systems.
The more common HAIs include:

 Central line-associated bloodstream infections (CLABSI)

 Catheter-associated urinary tract infections (CAUTI)
 Ventilator-associated pneumonia
 Surgical site infections

The most common healthcare-associated infection (HAI) is usually caused by a "staff" infection -
one that is transmitted from a health care worker, or "staff," to a client.

Infection Control
Hand hygiene is the foundation of all infection control practices in health settings.
The following information provides an overview of the various processes used to
reduce or eliminate infections.

 Medical Asepsis

Referred to as "clean technique," medical asepsis includes any therapy, protocol or

medical procedure used to reduce the number and spread of microorganisms.

 Hand hygiene — the single most effective and important way to prevent the spread
of microorganisms:
o Friction — loosens the microorganisms so they can be removed
o Soap – non-antimicrobial soap and water or with antimicrobial soap and water if
contact with spores, including Clostridium difficile or Bacillus anthracis
 Disinfectants and antiseptics:
o Disinfectant: a substance that reduces the number of microorganisms, including
bleach solutions and Zephirin (or other quaternary ammonium compounds)
o Antiseptic: a substance that can be applied to skin to reduce the number of
microorganisms, including alcohol, povodine iodine solutions (such as Betadine®)
and 2% chlorhexadine solution such as (ChloraPrep®)
 Practices that interrupt transmission, such as the use of personal protective
equipment

 Surgical Asepsis

Surgical asepsis includes the practices that destroy all microorganisms and their
spores, such as steam under pressure, gas, radiation and chemicals. Some very
basic guidelines of surgical asepsis include:

 Only sterile objects may be placed on a sterile field

 Always hold your hands above the level of your elbows
 Do not reach over the sterile field
 The edges of a sterile field or container are considered contaminated (depending on
the resource, this is approximately 1-2 inches surrounding the border)

A sterile object will become contaminated under the following circumstances:

 Sterile touching clean becomes... contaminated

 Sterile touching contaminated becomes... contaminated
 Sterile touching "questionable" is... contaminated
 A sterile object or sterile field that is not in the range of vision is... contaminated
 An object held below a person's waist is... contaminated
 A sterile object that comes in contact with a wet, contaminated surface is…
contaminated (through capillary action)
 A sterile object becomes contaminated…with prolonged exposure to air

Standard & Transmission-based Precautions

Standard precautions are a set of infection control practices used to prevent the
transmission of bloodborne and other pathogens from recognized and unrecognized
sources. They are the basic level of infection control precautions that are used in
the care of all clients.

Standard Precautions

Standard precaution guidelines include:

 Wash hands with soap and water when visibly dirty or contaminated.
 Wash hands or use an antiseptic handrub:
o Immediately when there is direct contact with blood, body fluids, secretions,
excretions or contaminated items
o After contact with a person's intact skin, such as when taking a pulse or blood
pressure, or moving or repositioning a client
o After contact with inanimate objects, including medical equipment in the immediate
vicinity of the client
o After removing gloves
o Between client contact
 Wear gloves before touching anything wet or before performing invasive procedures
 Use masks, goggles, face masks and other personal protective equipment (PPE) to
protect mucous membranes of the eyes, nose and mouth when contact with blood
and body fluids is likely

Standard precautions also include respiratory hygiene/cough etiquette, safe

injection practices and the use of masks for insertion of catheters or injection of
material into spinal or epidural spaces via lumbar puncture procedures.

Transmission-based Precautions
Contact Precautions

Organisms can be transmitted by direct contact (from one infected person to

another person) or by indirect contact, through a contaminated intermediate
surface, object or vector (such as mosquitoes, flies, mites, fleas, ricks and rodents).

Epidemiologically important organisms for contact transmission: VRE (vancomycin-

resistant enterococcus) and Clostridium difficile (C. difficile). Staphylococcus aureus

You should wear a gown and gloves for all interactions that may involve contact
with the client or potentially contaminated areas in the client's environment.

With Clostridium difficile (C. diff) infections, you must wash your hands with soap and water
because alcohol-based hand sanitizer does not kill the spores.

Droplet Precautions

Respiratory droplets are generated when an infected person coughs, sneezes, talks
or during procedures such as suctioning, endotracheal intubation, cough induction
by chest physiotherapy and cardiopulmonary resuscitation. Transmission of these
large particle droplets occurs when they come in contact with the conjunctivae or
the mucous membranes of the nose or mouth of a susceptible person.

When close contact (typically within three feet or less) between the source client
and a susceptible person is required, you should use a standard surgical mask.

Epidemiologically important organisms for infectious agents transmitted through the

droplet route: group A Streptococcus (for the first 24 hours of antimicrobial
therapy), adenovirus, rhinovirus, Neisseria meningitidis, pertussis, influenza virus.

Airborne Precautions

Airborne precautions are used when microorganisms dispersed through the air over
long distances remain infective over time and distance.

To prevent the spread of airborne pathogens, the client should be placed in a room
with special airflow and ventilation systems (airborne infection isolation room or
AIIR) and nurses should use respiratory protection with a NIOSH-certified N95 or
higher level respirator when in the room.

Epidemiologically important organisms for infectious agents transmitted through the

airborne route: rubeola virus (measles), varicella-zoster virus
(chickenpox), Mycobacterium tuberculosis.

Neutropenic Precautions
 Neutropenic precautions are used to prevent infection in clients who have
neutropenia (low white blood cell counts) or are immunocompromised.

Which personal protective equipment (PPE) is used depends on the nature of

interaction and the potential for exposure to blood, body fluids or infectious agents.
Usually visitors are restricted and the client is in a private room.

Protecting Nurses
Injury is one of the hazards of direct nursing care. The physical demands of moving
and repositioning clients can result in musculoskeletal injuries, especially back
injuries. Needlestick injuries expose nurses to infection. Exposure to occupational
chemicals and the potential for violence also have severe consequences for a
nurse's health.

Turning & Repositioning Clients

To protect yourself and the client from injury, you must use your body correctly
when turning and repositioning clients and when transferring clients to and from
beds, chairs, wheelchairs, stretchers and toilets.
How you move or transfer a client will be based on:

 The client's level of dependence, such as whether the client can bear weight or
has upper body strength.
 Whether the client is alert, oriented and cooperative.
Based on your assessment and documented information, you will also need to
determine the amount of assistance needed and the type of equipment needed.
Since manual lifting is unsafe for clients and caregivers, mechanical equipment such
as ceiling- or Hoyer-type lifts should be used. You will need to know how the
equipment works and match it to the needs of the client and limitations of the
room/area before you move the client.

Repositioning a client in bed is never a one person task. If possible, the bed should
be flat, the height of the bed appropriate for staff safety (at the elbows). If
possible, the client should flex the knees and push on the count of three; otherwise,
you should use a slider board. You should take great care to reduce friction and
shearing when moving a client in bed.
Needlesticks
If you are stuck by a needle or other sharp object or get blood or other potentially
infectious materials in your eyes, nose, mouth, or on broken skin, you should
immediately flood the exposed area with water and then clean any wound with soap
and water or available skin disinfectant. You will then report the incident to your
employer and seek further medical attention.

Chemical Occupational Exposure

Hazardous chemical exposure may include aerosols, gases and skin contaminants
from cleaners and disinfectants, latex and pharmaceuticals. Medication
administration, handling contaminated linens, exposure to human wastes or being
involved in special procedures (such as administering antineoplastic drugs,
exposure to anesthetic gases) can adversely affect a nurse's health.

Workplace Violence
Nurses and UAP are increasingly experiencing verbal or physical abuse – such as
yelling, cursing, grabbing, scratching or kicking - from clients and visitors. Nurses
are more vulnerable to violence since they are the ones who most frequently
interact with clients and their families.

Many nurses consider violence by clients as part of the job and that some clients
cannot be held accountable for their violent actions, which is why many incidents of
violence go unreported. However, nurses must report incidents of violence.
Moreover, clients and visitors must be held accountable for their behavior. In fact,
many states have enacted enforceable legislation that make it a felony to assault or
batter nurses.

Incident Reports
Medication administration errors are one of the most common types of errors made
by nurses. When you realize that you made an error, the first action should be to
report the error to the first person in the chain of command (usually the charge
nurse); the prescriber must also be contacted and orders implemented. After caring
for the patient, you will need to complete an incident (or occurrence) report.

By reporting errors, you are helping to improve processes or create new processes
to minimize errors and risk of harm to patients.
 When to Complete an Incident Report

in addition to reporting a medication administration error, an incident report

(The written documentation of unusual incidents such as medication errors, acts of
omission and commission, client falls and conflicts with clients and their families;
also referred to as an occurrence report.) should be filed whenever any unexpected
event occurs. For example, an incident report is required for the following
situations:

 Any time a client makes a complaint.

 A medical device malfunctions.
 Anyone – clients, staff or visitors – is injured or involved in a situation with the
potential for injury.

 General Guidelines

All organizations have specific guidelines for completing the report, you should
always remember to stick to the facts and report the following information:

 Date, time, and exact location of the occurrence (if the specific details are not
known, document the date and time the error was discovered)
 Names of persons involved in the incident and any witnesses
 Direct quotes from the persons involved in the incident
 Objective information describing the incident
 Who was notified about the error
 Orders received
 If indicated, corrective actions taken

The incident report is not part of the patient's medical record and, in most cases, is protected
from discovery during a legal investigation.

Security Plans
A written security plan is designed to protect clients, visitors and staff. The plan
identifies security threats in all areas of a health care facility that could have an
adverse impact on persons and property.

Health care organizations are required to identify security-sensitive locations within

the hospital that may require unique security protection, including mother-baby
units, pediatric units, emergency department, (inpatient) psychiatry, radiation
therapy, nuclear medicine, pharmacy, medical records, information services, human
resources, food services and surgical services.
 Physical protection may include closed-circuit television or video surveillance, time
delay locks and alarm systems, panic alarms, special locks, protective barriers,
security presence and/or dedicated security patrols.

Emergency Department
Examples of security in the emergency department (ED):

 All individuals may be screened when entering the unit

 All personal items are screened with an X-ray unit
 All interior and exterior doors leading to client care areas are equipped with
electronic access control
 The locked psychiatric unit within the ED are controlled by electronic access
control and monitored via digital camera system

Mother-baby Unit
There are multiple tools and devices used to protect against infant abduction in the
mother-baby unit:

 All entrances have an electronic locking mechanism

 All employees must use their badge to enter; guests must be cleared before
entering
 A digital surveillance system records activity 24/7 and stores data for a specific
period of time (usually 30 days)
 All ingress/egress doors are equipped with an infant protection system
 Security measures for newborns (with matching devices for mother and
father/support person) may include tamper-proof umbilical tags, cord clamps,
wrist and ankle bracelets

Emergency Preparedness
Explosions

Explosions or blasts can cause unique patterns of injury. Most injuries involve
multiple penetrating injuries and blunt trauma. All bomb events have the potential
for chemical and/or radiological contamination.
 Treatment overview:

 Lung injuries
o High flow oxygen sufficient to prevent hypoxemia via non-rebreather mask, CPAP
or ET tube
o Ensure tissue perfusion but avoid volume overload
o Prompt decompression for clinical evidence of pneumothorax or hemothorax
 Abdominal injury - clinical signs can be subtle at first; observe for acute abdomen
or sepsis
 Ear injuries may include tinnitus or deafness
 Crush injuries - sudden release of a crushed extremity may result in reperfusion
syndrome (acute hypovolemia, renal failure, metabolic abnormalities)
o IV fluid replacement (up to 1.5 L/hour)
o To help prevent renal failure - mannitol to maintain diuresis at least 300
mL/hour; dialysis may be needed
o To treat acidosis - IV sodium bicarbonate until urine pH reaches 6.5 (to prevent
myoglobin and uric acid deposition in the kidneys)
o To treat hyperkalemia/hypocalcemia - calcium gluconate 10% 10 mL or calcium
chloride 10% 5 mL IV over two minutes; sodium bicarbonate 1 mEq/kg IV push
(slowly); regular insulin 5-10 units and D5O 1-2 ampules IV bolus; kayexalate
25-50 g with sorbitol 20% 100 mL PO or PR
 Monitor injured areas for the five Ps: pain, paresthesia, paralysis, pulse and pallor
 Monitor for sepsis
 Injuries resulting in non-intact skin or mucous membrane exposure - hepatitis B
immunization (within seven days) and tetanus toxoid vaccine

Natural Disasters & Severe Weather

Clustered under this category are earthquakes, extreme heat, floods, hurricanes,
tornadoes, tsunamis, volcanoes, wildfires, landslides/mudslides and winter weather.

Traumatic events following natural disasters are characterized by a sense of horror,

helplessness, serious injury or the threat of serious injury or death.
 Radiation Emergencies

Radiation emergencies can be caused by radioactive material that contaminates

food and/or water and bombs (such a dirty bombs) or other weapons of mass
destruction.
The severity of signs and symptoms of radiation sickness depends on how much
radiation has been absorbed.

 Mild radiation sickness (absorbed dose of 1-2 Gy): nausea and vomiting,
headache, fatigue, weakness within 24 to 48 hours after exposure
 Very severe radiation sickness (absorbed dose of 3.5-5.5 Gy): nausea and
vomiting less than 30 minutes after exposure to radiation, dizziness,
disorientation, hypotension; usually fatal

Treatment overview:

 Decontamination:
o Remove clothing and shoes
o Gently wash victim with soap and water
 For damaged bone marrow:
o Filgrastim (Neupogen): a protein-based medication which promotes the growth of
white blood cells
o Pegfilgrastim (Neulasta): also increases white blood cells and prevents
subsequent infections
 For internal contamination (chelating agents):
o Potassium iodide (KI): used to prevent absorption of radioiodine in the thyroid
gland
o Prussian blue: a type of dye that binds to particles of radioactive elements
(cesium and thallium)
o Diethylenetriaminepentaacetic acid (DTPA): binds to particles of the radioactive
elements plutonium, americium and curium
 Supportive treatment for infections, headache, fever, diarrhea and dehydration;
also end-of-life care
 Disease Outbreaks

The more common foodborne outbreaks include Salmonella, Listeria and E. coli.

Other recent outbreaks include Ebola virus disease, Avian influenza, Middle East
respiratory syndrome coronavirus (MERS-CoV), H1N1 and Zika virus.

Recent vaccine-preventable disease outbreaks include mumps, measles, polio and

pertussis (whooping cough).

Terrorism & Disease

The following list of agents and/or diseases that may be used in a terrorist attack.
The list is divided into three categories (as suggested by the Centers for Disease
Control and Prevention) based primarily on mortality rates.

 Category A

Biological agents with the highest probability of mass dissemination or person-to-

person transmission and high mortality rates.

 Anthrax (Bacillus anthracis)

 Botulism (Clostridium botulinumtoxin)
 Plague (Yersinia pestis)
 Smallpox (Variola major)
 Tularemia (Francisella tularensis)
 Viral hemorrhagic fevers, including Ebola, Marburg and Lassa

 Category B

Second highest priority agents, mostly due to lower morbidity and mortality rates:

 Brucellosis (Brucella species)

 Epsilon toxin of Clostridium perfringens
 Food safety threats (including Salmonella species, Escherichia
coli O157:H7, Shigella)
 Glanders (Burkholderia mallei)
 Melioidosis (Burkholderia pseudomallei)
 Psittacosis (Chlamydia psittaci)
 Q fever (Coxiella burnetii)
 Ricin toxin from Ricinus communis (castor beans)
 Staphylococcal enterotoxin B
 Typhus fever (Rickettsia prowazekii)
 Viral encephalitis (alphaviruses)
 Venezuelan equine encephalitis
 Water safety threats (such as Vibrio cholerae, Cryptosporidium parvum)

 Category C

Third highest priority agents, including emerging pathogens that could be

engineered for mass dissemination in the future:

 Nipah virus
 Hantavirus

Triage & Mass Casualties

An emergency response plan includes information used to determine which client(s)
to recommend for discharge in a disaster situation and identify nursing roles in
disaster planning. All employees participate in disaster planning activities and drills
and nurses should understand their responsibility in implementing emergency
response plans for internal and external disasters.

Regardless of the triage system used, the primary goal is to quickly sort victims
into categories and identify each of them, using a tag, tape or some other means.
Triage is intended to do the greatest good for the greatest amount of people. A
common triage system for a mass casualty event is the START triage system. This
system uses a red, yellow, green, black tag system.

 Community Setting

victims are categorized based on the severity of the injury, the urgency of needed
treatment and an available place for treatment:

 Treated first: individuals who have life-threatening injuries that are readily
correctable.
 Treated last:
o Individuals who have no injuries (noncritical injuries) and who are ambulatory.
o Individuals who are dying or are dead.
  Health Care Settings

Triage in the emergency department usually involves dividing those who need care
into one of the following three categories:

 Emergent – individuals who have life-threatening injuries and need immediate

attention are given the highest priority
 Urgent – individuals with non-life-threatening injuries
 Nonurgent – individuals with no immediate complications and who can wait for
treatment