Factors Affecting Safety

People’s ability to protect themselves from injury is affected by such factors as age and
development, lifestyle, mobility and health status, sensory–perceptual alterations, cognitive awareness,
emotional state, ability to communicate, safety awareness, and environmental factors. Nurses need to
assess each of these factors when they plan care or help clients learn to protect themselves.

Age and Development

The age-dependent cognitive, psychological, language, and physical changes that occur across
the lifespan influence an individual’s ability to identify, anticipate, prevent, and recover from a range of
health risks. Consider the following examples: Toddlers and preschool-age children are attracted to
bodies of water but generally lack the ability to sense danger. This, compounded by the fact that a top-
heavy physique makes them more prone to falling into the water, places them at high risk for drowning.
Very young children can easily sustain burns if exposed to very hot water (greater than 49°C), as their
dermis is thin. The adolescent, whose thoughts usually include the personal fable, may believe that he
or she is immune to adverse outcomes when engaging in risky behaviour. In older adults, the
combination of reduced reflex activity and diminished sensory acuity can lead to increased risk of falling.

Lifestyle

Lifestyle factors that place people at risk include unsafe work environments; living in
neighbourhoods with high crime rates; access to firearms; abuse of alcohol and illicit drugs, which may
be contaminated by harmful additives; and lack of income to buy safety equipment (e.g., car seat).

Mobility and Health Status

People with impaired mobility related to paralysis, muscle weakness, or poor balance or
coordination are at increased risk of injury. People with paraplegia may be unable to move even when
they perceive discomfort, and those with peripheral neuropathy (an unfortunate yet relatively frequent
complication of diabetes mellitus) may not even perceive discomfort and thus sustain injury or skin
breakdown. People with hemiplegia and those with leg casts often have poor balance and fall easily.
Clients weakened by illness or surgery may not be fully aware of their limitations, which places them at
risk for falls or other injury.

Sensory–Perceptual Alterations

Accurate sensory perception of environmental stimuli is vital to safety. People with impaired
perception of touch, hearing, taste, smell, and vision are highly susceptible to injury. A person who does
not see well may trip over an object; a person with hearing impairment will not hear a siren in traffic;
and people with anosmia (impaired olfactory sense) may not smell burning food or the odour of a gas
leak.
 Cognitive Awareness

Awareness is the ability to perceive environmental stimuli and physical reactions and to respond
appropriately through thought and action. Clients with impaired awareness include people lacking sleep,
unconscious or semiconscious persons, disoriented people who may not understand where they are or
what to do to protect themselves, people who imagine nonexistent stimuli, and people whose judgment
is altered by disease or medications (e.g., opioids, tranquilizers, hypnotics, and sedatives).

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 or may be considering suicide (a leading form of intentional injury).

Ability to Communicate

Individuals with diminished ability to receive and convey information are at risk for injury. They
include people with aphasia (loss or impairment of the power to use or understand words, usually
resulting from brain damage), people with language barriers, and those unable to read. For example, the
person unable to interpret the sign “No smoking: oxygen in use” could cause a fire or an explosion.

Safety Awareness

Information about water safety, car safety, fire prevention, and the many age-specific hazards
and their preventive measures is crucial to safety. Clients in unfamiliar environments (e.g., hospital) or
dealing with new treatments (e.g., oxygen therapy, hot packs) frequently need specific safety
information.

Environmental Factors

Depending on the client’s situation, the nurse may need to assess the environment of the home,
workplace, or community. While clients generally seek out the health care setting to improve their
health, client safety may also be adversely affected by the health care setting environment, including
health care in the home.

Home A safe home requires, among many things, wellmaintained floors and carpets, a nonskid
bathtub or shower surface, strategically placed and functioning smoke alarms and carbon monoxide
detectors, and fire escape routes that residents are aware of. Outdoor areas, such as swimming pools,
need to be safely secured and maintained. Adequate lighting, both inside and out, will minimize the
potential for unintentional injury. Families living on farms are exposed to particular risks, as their homes
are also workplaces, where heavy equipment, large vehicles, open water, and animals are often present.

Workplace A range of chemical, biological, physical, ergonomic, and psychosocial hazards exist
in the workplace. Workers exposed to temperature extremes, those who lack adequate training on the
use of mechanical equipment, or those who are the victims of sexual harassment or discrimination in
the workplace are all at risk for ill health. Young, new workers, and migrant or immigrant workers are
employed in disproportionate numbers in physically demanding or hazardous jobs, which places them at
higher risk for workplace injuries and illnesses (Canadian Centre for Occupational Health and Safety,
2015). The work environment of the nurse includes risks to safety, such as exposure to microbial agents,
musculoskeletal injury related to moving patients, and potentially aggressive clients.

Community Adequate street lighting; safe water and sewage treatment; restrictions on
pollution, including smoke-free environments; and regulation of consumer products and 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, poor-quality housing, or
unprotected creeks and landfills. Communities rely on coordinated local, provincial, and national
emergency preparedness and response resources when the safety of communities at large is at risk,
such as in the event of natural events and disasters (e.g., floods, forest fires, earthquakes, fires, and
highly dangerous infectious diseases) and accidents or criminal and terrorist acts involving explosives,
chemicals, radioactive substances or biological materials.

Health Care Setting, Including Home Care Safety issues within the Canadian health care setting
have come to the forefront since the release of the Canadian Adverse Events Study (Baker et al., 2004)
indicating that a high number of hospitalized patients (1 in 13) can experience adverse events, including
death, with many of these events deemed preventable. With reports of numerous patients (1 in 10)
harmed while receiving hospital care, the World Health Organization (WHO) has declared patient safety
a serious global public health issue (WHO, 2014).

Safety problems in the health care setting can arise from acts of omission (failure to institute the
appropriate therapeutic intervention), such as lack of assessment to predict risk of falls or lack of
discharge teaching, or acts of commission (incorrect diagnosis or treatment, or poor performance), such
as errors in medication dosage, wrong-site surgery, restraint-related injuries or death, burns, mistaken
identity, and health care-associated infection. Multiple factors can contribute to errors, such as a gap
between the increased complexity of care in health care settings and outdated communication systems,
poor product design, a shortage of qualified health care personnel, dysfunctional communication
patterns among health care professionals, poor quality of the nursing practice environment, ineffective
nursing staffing and skill mix, among others. Client safety is viewed as going beyond placing the blame
on individual professionals to looking at the multiple system factors and their complex interplay that
ultimately influences whether patient safety is ensured.

Effective interprofessional communication and collaboration also promote client safety and
quality assurance in health care, and thus many professional schools have tried to develop opportunities
for nursing students and other students in the health care professions to learn with, from, and about
each other—all in an effort to improve patient safety.

Client safety concerns also occur in home care situations. Family members, friends, and informal
caregivers under the indirect supervision of medical personnel are taking on complex care, such as
administering intravenous antibiotics, caring for a partner who is paralyzed, helping a family member
recover from a major surgical intervention, or caring for a family member who is dependent on a
respiratory ventilator. The seminal work Safety at Home: A Pan-Canadian Home Care Study (Canadian
Patient Safety Institute, 2013) revealed that individuals receiving home care experienced adverse events
at an annual rate of 10% to 13%, with over half such events deemed preventable; thus people receiving
care at home are as vulnerable to care-associated injury as those receiving care in the hospital. The
safety of caregivers in families may also be at risk as they take on difficult tasks, such as lifting heavy
equipment or moving their family member in and out of bed or a bath. (See Evidence-Informed Practice
box for further discussion related to safety at home)

Evidence-Informed Practice

What Are the Major Patient Safety Issues in Home Care in Canada?

The Canadian Patient Safety Institute funded a study that explored, for the first time in Canada,
issues related to patient safety in home care. As in the case of those receiving care in the hospital
setting, people receiving home care are experiencing high rates of adverse events (13%) with over half
(56%) such events deemed preventable. The main types of adverse events identified are falls,
medication incidents, and infections (mostly occurring in the first 30 days of receiving home care).
Interviews with clients and their caregivers revealed six themes: (1) the unacknowledged challenge of
providing health care in a private home; (2) a fragmented system of home health care delivery; (3)
“creeping” increases in care that unpaid and untrained caregivers must provide in spite of their own
health challenges; (4) “rationing” of oxygen concentrators, especially for people with chronic obstructive
pulmonary disease (COPD), and the subsequent impact on quality of life; (5) clients “doing what it takes”
to be able to stay home—sometimes to the point of hiding their needs; (6) and the decline in the health
of caregivers (often seniors).

Nursing Implications: As more and more health care is shifted into the home setting, nurses
must be aware of the challenges and risks placed on the clients and caregivers in this setting. This study
indicates a fine balance between the benefits and client wishes of staying at home and the risks to
clients and their caregivers. Nurses who work in home care can advocate for better training of lay health
care providers and can influence policymakers on such matters as the need for improved intersectoral
collaboration (e.g., between home care and institutional care); an integrated approach to home health
care (rather than letting caregiver “duty creep” happen); improvements in medication packaging and
equipment for lay users; and improved utilization of risk assessment tools.

Assessing

Assessing clients at risk for unintentional injury involves (a) noting pertinent indicators in the
nursing history and physical examination, (b) using specifically developed risk-assessment tools, (c)
evaluating the client’s home environment, and (d) assessing standards related to patient safety goals in
hospitals.

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 of physiological or perceptual deficits, such as olfactory, visual, tactile, taste, or
other sensory impairments; altered thought processes or impaired cognitive or emotional capabilities;
problematic substance use; indications of abuse or neglect; and a history of unintentional injury. A
safety history also includes the client’s awareness of hazards, knowledge of safety precautions at home
and at work, and any perceived threats to safety (Figure 32.1).

Risk-Assessment Tools

Risk-assessment tools are available to determine which clients are at risk for specific kinds of
injury, such as falls, or for the general assessment necessary to keep clients safe in their homes and in
health care settings. In general, these tools direct the nurse to appraise multiple factors affecting safety.
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.

Home Hazard Appraisal

Hazards in the home are major causes of falls, fire, poisoning, suffocation, and other incidents,
such as those caused by improper use of household equipment, tools, and cooking utensils.

National Patient Safety Goals

Accreditation Canada plays a major role in improving patient safety through the accreditation of
Canadian health services organizations. The accreditation program evaluates how organizations meet
standards of excellence in ensuring patient safety and providing quality services relative to meeting six
Required Organizational Practices (Accreditation Canada, 2016):

1. Safety culture, as evidenced by such indicators as a documented and coordinated

approach to disclosing patient safety incidents to clients and families
2. Communication (effective information transfer with clients and team members across
the continuum of care), as evidenced by such indicators as the following:
 Clients and families are informed about their role in promoting safety, with staff
taking client or family questions or comments about potential error seriously
 Not using dangerous abbreviations, symbols, and dose designations so as to
avoid medication errors (see Chapter 33)
 Effective mechanisms for transfer of information at care transition points, such
as change of shift, transfer between units or institutions, and discharge home
 Reconciliation of clients’ medications at admission and transfer or discharge
(discussed in detail in Chapter 33)
 A safe-surgery checklist used to confirm safety steps during surgical procedures
(see Chapter 36)
 Clients properly identified using two person-specific indicators before any
service or procedure (Practice Guidelines 33.1 in Chapter 33)
3. Ensuring the safe use of medications, as evidenced by the following indicators:
 Absence of concentrated electrolytes (e.g., potassium chloride ≥2 mmol/L,
sodium chloride >0.9%) from client service areas
 A limited number of heparin concentrations being available on the care unit,
with high-dose formats (e.g., unfractionated heparin 10 000 U/mL) provided
only on a client-specific basis (i.e., not as a stocked medication)
 Adequate and ongoing training for staff on the use of all infusion pumps
 High-alert medications (e.g., insulin, opioids, sedatives, antithrombotics) are
managed effectively (see Chapter 33 for further discussion)
 High-dose, high-potency opioids are removed from patient care units (Chapter
33 provides an in-depth discussion on safety with respect to medications) •
Antimicrobial stewardship that includes appropriate selection, dosing, route,
and duration of antimicrobial therapy.
4. Creating a work life and physical environment that supports the safe delivery of care
and service, as evidenced by the following:
 Training on client safety for all staff
 Staff having a clear understanding of the roles, responsibilities, and
accountabilities of the health team members in relation to the care and safety
of patients or clients Preventive maintenance programs for medical devices,
medical equipment, and medical technology
 Comprehensive strategy to prevent workplace violence
5. Reducing the risk of health care-associated infections and their impact across the
continuum of care and service, as evidenced by the following:
 Ongoing evaluation of compliance with hand-hygiene practices for staff, service
providers, and volunteers
 Adherence to international, federal, and provincial or territorial infection
control guidelines
 Tracking and analysis of health care-associated infections
 Implementation of protocols to ensure the administration of the
pneumococcal vaccine
 Monitoring of processes for reprocessing (cleaning, disinfecting, sterilizing)
equipment
6. Identifying safety risks inherent in the client population, as evidenced by the following:
 Falls-prevention strategy
 Safety risk assessment for clients receiving services in the home
 Assessment of risk for developing pressure injury, with implementation of
interventions to prevent pressure injuries
 Use of an interprofessional and collaborative approach to assess clients who
need skin and wound care and provision of evidence-informed care that
promotes healing and reduces morbidity and mortality
 Assessment and monitoring of clients for risk of suicide
  Identification of clients at risk for venous thromboembolism (pulmonary
embolism and deep vein thrombosis) with provision of appropriate prevention
strategies

Accreditation Canada focuses on system-wide indicators of safety, marking a shift from the
method of finding out who made any particular error (i.e., creating an environment of fear and
scapegoating) to analyzing the system to find out why any particular error occurred (i.e., creating an
environment of learning and improvement).