Accident/Error and Incident Prevention: NCLEX-RN
In this section of the NCLEX-RN examination, you will be expected to demonstrate your knowledge and skills of accident / error and incident prevention in order to:
- Assess clients for allergies and intervene as needed (e.g., food, latex, environmental allergies)
- Determine client/staff member knowledge of safety procedures
- Identify factors that influence accident/injury prevention (e.g., age, developmental stage, lifestyle, mental status)
- Identify deficits that may impede client safety (e.g., visual, hearing, sensory/perceptual)
- Identify and verify prescriptions for treatments that may contribute to an accident or injury (does not include medication)
- Identify and facilitate correct use of infant and child car seats
- Provide the client with appropriate method to signal staff members
- Protect the client from injury (e.g., falls, electrical hazards)
- Review necessary modifications with client to reduce stress on specific muscle or skeletal groups (e.g., frequent changing of position, routine stretching of the shoulders, neck, arms, hands, fingers)
- Implement seizure precautions for at-risk clients
- Make appropriate room assignments for cognitively impaired clients
- Ensure proper identification of client when providing care
- Verify appropriateness and/or accuracy of a treatment order
Patient, resident safety is a major concern in healthcare organizations. The Joint Commission on the Accreditation of Healthcare Organization (JCAHO) publishes patient safety goals on an annual basis to facilitate client safety.
The Hospital Patient Safety Goals for 2016 include the goals to:
- Identify patient safety risks
- Identify patients correctly
- Improve staff communication
- Use medications correctly
- Use patient safety alarms correctly
- Prevent infections
- Prevent errors and mistakes relating to surgery, other invasive procedures, and treatments
More information about the current Patient Safety Goals put forth by the Joint Commission on the Accreditation of Healthcare Organization (JCAHO).
Upon first contact with the client, the nurse thoroughly assesses the client for any known allergies, in addition to many other bio-psycho-social-spiritual data. These allergies can be related to medications and other substances such as contrast media that is used for many diagnostic tests, foods, environmental factors like pet dander and air pollution and other things like an allergy to latex and products containing latex.
Nurses determine, identify and document client allergies to medications, contrast media used for diagnostic tests, foods, and environmental sources including latex.
Nurses observe for and identify any possible allergies to the medications. For example, nurses collect data relating to past medication allergic responses and they also observe patients throughout the course of care to determine if the patient is experiencing an allergic response to a new medication. For this reason, nurses must be fully informed about the signs and symptoms of an allergic response to all medications that they administer.
All allergies to medications are documented in the nursing assessment and also on the medication administration record in addition to other areas in the medical record, according to the facility's policy and procedure. Many healthcare agencies also use allergy bands and/or bar codes with embedded allergy information to enable nurses to readily identify any allergies to medications.
Similar to latex allergic responses, the degree, intensity and seriousness of allergic responses to medications can be moderate or severe.
Commonly occurring medication allergies include allergies to penicillin which can be particularly dangerous and life threatening, allergies to sulfonamides, and allergic reactions to cephalosporin medications.
Commonly occurring allergies to radiocontrast media include allergies to ionic high osmolality contrast media and nonionic low osmolality contrast media. Some of the risk factors associated with allergies to radiocontrast media include beta blocker antihypertensive medications, the elder years, female gender, and a history of renal disease and/or heart disease.
It is estimated that nearly 10% of people have a reaction to penicillin. Some of these reactions are an allergic response and others are simply a side effect. The first exposure to penicillin, referred to as the "sensitizing dose", sensitizes and prepares the body to respond to a second exposure or dose. It is then the second exposure or dose that leads to anaphylaxis, or anaphylactic shock.
The signs and symptoms of anaphylaxis and anaphylactic shock, a type of distributive shock, are the massive collapse of venules and arterioles in the body's circulatory system, decreased cardiac output, histamine release, a drop in blood pressure, pooling of venous blood, laryngeal edema, respiratory distress, a rash, a rapid bounding heart beat, and death unless it is immediately treated.
Like a penicillin allergy, allergies to latex and its effects on the body can vary among individuals in terms of its severity. For example, some clients may only be affected with an immediate local contact dermatitis, the least severe of all the allergic reactions to latex, others can be affected with a delayed contact dermatitis, and still move can respond with a life threatening allergic reaction which can be signaled with itching and flulike symptoms and progress to tachycardia, hypotension, dyspnea, chest pain tremors, and anaphylactic shock.
The signs and symptoms of immediate and delayed contact dermatitis to latex include itching and burning of the skin and skin scaling that can extend the area of contact such as the hands when latex gloves are used.
Allergies to latex can occur after long use and they can also occur with the first contact with latex.
Some of the patients at greatest risk for latex allergies are those with some immunosuppressive disorder such as HIV/AIDS, those with asthma and eczema. It is also believed that those who are allergic to some foods, like avocados, are more at risk for latex allergies than others without these food allergies.
Learn more about the role of HIV/AIDS nurses.
In summary, nurses must be knowledgeable about assessing known and possible client allergies including those to medication, other medical substances such as latex and contrast media, foods and environmental factors, the signs and symptoms of an allergic response, and interventions that must be done when the client is affected with an allergic response. Some of these interventions can include reporting, documentation and interventions to correct any allergic responses and changes that can impact on the client's healthcare status. For example, CPR and other life saving measures may be indicated when the client is affected with life threatening anaphylactic shock; and the nurse may have to administer corticosteroid medications with a doctor's order after an allergic response was communicated to the client's physician.
Staff is required to have the knowledge, skills and abilities to identify safety risks, to intervene appropriately to prevent and correct safety hazards and to act accordingly when a client, family member, visitor or another staff member is actually or potentially affected by a safety hazard.
When a staff educational need related to these or other aspects of safety, the registered nurse, will plan, implement and evaluate education to meet these needs. After education is provided, the staff member will be assessed for their competency.
Some safety skills, such as using a fire extinguisher, are rarely used skills and others, such as daily surveillance of the patient care area for safety hazards and risks, are frequently used skills. Both, rarely used and frequently used safety skills, however, are associated with high risk, therefore, rarely used skills must be assessed and staff must be deemed competent on a frequent basis with observation; and frequently used safety skills can be validated for competent performance with the indirect observation of the application of these skills and the identification of any issues or discrepancies in the performance of these skills. For example, the staff member should actually demonstrate the correct use of a fire extinguisher in a planned manner and at least on an annual basis and the competency levels of staff related to frequently used safety skills can be determined and validated indirectly by observing the correct application of these skills in the area of employment.
Clients also may have safety educational needs. For example, clients at risk for incidents, accidents, and errors should be instructed about safety procedures and measures that they can use to prevent them. For example, some clients may need frequent reminders to call for help before getting out of bed to prevent a fall, and others may need the nurse to educate them for the need for grab rails and to have a carbon monoxide alarm in the home.
Some of the factors that can positively impact on and influence injury and accident prevention include an age and developmental stage at which the person is able to understand safety and safe behavior; a normal, alert and awake level of consciousness, a level of cognitive ability and mental status that enables the person to have insight into safety and safe behaviors and fully aware and cognizant of their own limitations, strengths and weaknesses; and a lifestyle including exercise and an adequate diet that can enhance their health, well-being and level of safety.
In terms of age, infants, toddlers, young children and the elderly very young are at greater risk for accidents and injuries than other age groups; people with poor consumption patterns, such as illicit drug and/or alcohol abuse, are more prone to injuries and accident than those who have healthy lifestyle choices that increase their strength, stamina, agility and nutritional status.
Physical deficits like sensory losses and alterations, impaired mobility, an altered mental and emotional state, and other factors can negatively impact on the safety of the client.
Sensory and Perceptual Deficits
Physical deficits like a sensory losses and alterations can affect client safety. For example, clients with a visual impairment may trip over objects that they cannot see and they can also fail to see a sign that indicates that a floor is wet; and patients with a hearing deficit may not hear a fire or smoke alarm.
Patients affected with permanent or temporary losses of mobility are more prone to injuries and accidents than other patients without these deficits. For example, a client with left sided paralysis as the result of a cerebrovascular accident and a client who has become weak as the result of prolonged complete bed rest are at greater risk for injuries and accident than those without these conditions.
An Altered Mental and Emotional State
High levels of stress, fatigue, the effects of some medications like sedating medications, the effects of anesthesia, and depression are risk factors associated with a greatest risk for client injuries and accidents than other clients with intact and unimpaired mental and emotional states.
A Lack of Safety Insight
A lack of good judgment and insight into safety risks place clients at risk for safety concerns.
Identifying and Verifying Prescriptions for Treatments That May Contribute to An Accident or Injury, Not Including Medications
An essential component of injury and accident protection entails the ability of the nurse to identify and verify all treatment orders and prescriptions to insure that they are not placing the client at risk for any injury or accident. When the nurse receives an order or prescription for a treatment or procedure that is questionable in terms of client appropriateness and safety, the nurse, as the nurse does with questionable medication orders, contacts the person who has prescribed the treatment or procedure and verifies the order before carrying this order out.
The treatments and procedures that are most prone to client risk, injuries and accidents and the most risky are invasive procedures including surgery and invasive diagnostic tests. It is, therefore, essential that nurses exercise extreme caution and apply their knowledge of the client's status and the risks associated with the particular treatment to the particular order to insure that undue risks are not associated with the invasive treatment or procedure that has been ordered.
Some of the procedures associated with high degrees of risk intraprocedure or treatment and after the treatment or procedure include all surgical procedures, invasive cardiac catheterizations, intubation, peripheral venous catheters, central venous catheters, chest tubes, mechanical ventilation, the administration of contrast media for diagnostic tests and other procedures and treatments, some of which will be discussed in a later section entitled The Reduction of Risk Potential.
When properly used and fitted, infant and child death and injury secondary to motor vehicle accidents can be significantly, according to the National Highway Traffic Safety Administration (NHTSA). It is estimated that infant and child car seats prevent death among infants by 71% and among toddlers and young children under 3 years of age by 54%.
Infant seats and car seats must be properly sized and properly installed in order for them to be effective against injures and death. For example, rears facing infant seats are always installed in the back seat facing the rear of the car when the infant or baby is less than about 2 years of age and about 20 to 30 pounds. Convertible safety seats can be both rear facing and front, or forward, facing. Regular car seat belts can be typically used when the child is at least 40 pounds and about 4 years of age.
Many accidents and client injuries can be prevented when the client has access to a device that enables them to signal staff and when these calls to staff members are responded to in a timely manner. Nurse call bells that continue ringing for minutes without being responded to by staff can, and do, lead to unnecessary injuries and accidents that could have been prevented by a prompt staff response. Regardless of the method for alerting staff is used, calls for help and assistance must be immediately responded to.
At times the method to signal and alert nursing staff members must be modified according to the client's characteristics and needs and at other times the method to signal and alert nursing staff members must be modified according to a situation or circumstance in the environment that is not related to the client and their abilities.
Most clients are able to signal staff with a call bell and light. Others may only be able to verbally call out for help, and others may not be able to signal staff members. Clients unable to use a call bell should be placed near the nursing station or another area with high activity so the client's verbal calls for help can be heard and attended to by staff; clients unable to call for help using a call signal or verbal calls for help should not only be placed in a room near the nursing station or another area with high activity so that they can be monitored and observed on a frequent basis.
When there is a utility failure, or another environmental factor such as the malfunction of the facility's call bell system, that disrupts the use of call bells, hand held bells or buzzers should be provided to the clients so they can communicate with nursing staff despite this electrical power loss or system malfunction.
Healthcare providers and healthcare facilities are mandated to protect clients, visitors and staff from injury. Some of the commonly occurring injuries in healthcare facilities include burns, falls, electrical shock, accidental poisoning and events occurring from internal and external disasters.
Thermal injures can occur as the result of faulty warming and cooling devices and also with the improper application of heat and cold to the client, particularly when the client has a sensory and/or neurological deficit that impairs their ability to sense and feel skin damage resulting from the heat or cold application. More information about the safe and correct application of heat and cold will be discussed later in this NCLEX-RN review.
Falls a major, commonly occurring and costly accident, with or without injury, plague virtually all health care facilities. For this reason, all clients should be screened and assessed for falls risk upon admission, upon our first client contact and, also, whenever the client's condition is marked with significant physical and/or psychological or cognitive changes.
When a client is screened and assessed as a falls risk client, special interventions to prevent falls must be immediately initiated, communicated and documents.
Some of the risk factors associated with falls that are typically included in a falls risk screening and assessment are:
Patients who are incontinent of feces and/or urine are at greater risk for falls than clients who are not affected with these elimination problems. Incontinent patients may leave feces and/or urine of the floor which they may slip on and/or they may be in such a hurry to get to the toilet that they fail to use proper lighting and other safety measures to prevent a fall.
Confusion can lead to poor judgment and a lack of awareness of environmental factors that can lead to a fall. People who are confused may lack good judgment and they may not be aware of any hazards.
People who are visually impaired can trip over things they cannot see, particularly in a strange, or new, environment. Clients should be given their eyeglasses and encouraged to use them.
A delayed and slow reaction time
A delayed and slow reaction time, a normal change associated with the aging process, places clients at greater risk than others, and often younger, clients. They may not react quickly enough to avoid a hazard, such as a wet floor, that they see. This can lead to a slip and fall.
The aging population, infants and young children are the age groups that are at greatest risk for falls.
Sedating medications and other medications with some side effects, such as fatigue, muscular weakness, dizziness, and orthostatic hypotension, for example, increase a client's vulnerability to falls.
Poor muscular strength, balance, coordination, gait and range of motion (ROM)
When a client has poor balance, coordination, proper gait, and full range of motion for one reason or another, they are at greater risk for falls than other clients without these deficits. One of the most effective interventions to address these deficits is to employ the services of the physical therapist to increase the client's muscular strength, balance, coordination, gait and range of motion in order to prevent falls.
Patient rooms and client areas that have clutter, poor lighting, high glare, wet floors and/or an absence of nurse call bells are not safe. The nurse is responsible to keep the client environment safe and without any hazards.
A history of falls in the past, particularly more recent and frequent falls, place a client at future risk for falls because many of the same conditions that were present in the past, particularly the recent past, may continue to the current time. For example, paralysis secondary to a cerebrovascular accident persists over time.
Fear of falling
A client's fear of falling has been shown to be positively correlated with falls risk.
Some diseases and disorders
Some diseases and disorders, particularly those that adversely affect the client's musculoskeletal and/or neurological status, place a client at risks for falls. For example, diseases and disorders like muscular dystrophy, Parkinson's disease and a seizure disorder place a client at risk for falls.
In addition to intrinsic, patient related factors that place clients at risk for falls, there are also a number of extrinsic and environmental factors that place clients at risk for falls.
Some of these factors, all of which must be immediately corrected, include:
Inadequate patient foot wear
Poorly fitting, nonskid proof and simply dangerous shoes and slippers place clients at risk for falls. Patient footwear should be skid proof, sturdy, properly fitted and safe. Skid proof socks are highly effective in terms of fall prevention.
Broken equipment and the inappropriate use of patient equipment
Broken patient equipment such as a broken wheelchair or cane can lead to falls. All broken equipment must be reported and immediately removed from service and not used until they are repaired and deemed safe to use. All patient equipment must also be used correctly. When a staff member improperly uses a mechanical lift, for example, to move the client from the bed to the chair and the patient falls as the result of this improper use, an accident and injury has occurred as the result of this improper use of the mechanical lift.
No answers to calls for help
As previously stated, all calls from clients must be responded to promptly in order to prevent falls as well as other incidents and accidents, many of which can lead to patient injury.
In addition to assessing clients for falls risk, some of the special interventions that can prevent falls or lessen the degree of injury that a client can sustain after a fall include the following:
- The use of patient assistive devices such as walkers and canes
- Padded briefs to decrease the extent of an injury when a client does fall despite preventive measures
- The use of padded gym mats on the floor next to a bed can also decrease the extent of an injury when a client does fall despite preventive measures
- The use of low beds to decrease the extent of an injury when a client does fall despite preventive measures
- The use of bed and chair alarms to alert staff that the client is rising from the bed or the chair
- More frequent patient monitoring and observation
- The use of high toilet seats and grab bars
Like other safety hazards, health care facilities are subject to incidents and accidents associated with things and practices that are contrary to good electrical safety. For example, frayed electrical cords and using extension cords that can overwork electrical outlets and also cause client tripping and falling can occur in health care facilities unless they are eliminated from the environments within which clients receive services and staff members work.
All electrical client equipment is routinely and predictably inspected for safety, and preventive maintenance is also done and documented on these pieces of electrical equipment. When a piece of equipment is overdue for this electrical inspection and maintenance and also when it is malfunctioning and/or with a frayed wire, this piece of electrical equipment must be immediately taken out of service and sent to the appropriate department for inspection, preventive maintenance and repair. Under NO circumstances should such equipment be used even on a very temporary basis. More about the safe use of equipment will be discussed below.
Client's personal electrical equipment, such as televisions, radios, electrical razors and computers, must also be inspected and approved as safe, by a person competent to do so, before it can be used by the client in the health care environment. For this reason, patients are discouraged from bringing personal electrical equipment into the health care facility for their personal use.
Reviewing Necessary Modifications with the Client to Reduce Stress on Specific Muscle or Skeletal Groups
Some of the things that nurses can facilitate and do in order to reduce stress on specific muscle and skeletal groups include encouraging clients to perform routine stretching, range of motion exercises and also frequently changing positions into those which place the body in a safe position.
Clients who are not able to do this must be positioned and repositioned every two hours into a position that will not cause any harm such as any stressors on the muscle groups, and that prevent skin breakdown and other complications associated with immobility such as contractures.
The client positions that are used for maintaining good bodily alignment and optimal physiological functioning include the Sim's or semi prone position, the Fowler's position, the dorsal recumbent position, the prone position and the lateral position. These positions are supported and maintained with pillow, bolsters and wedges when necessary to maintain correct bodily alignment.
Routine stretching and exercising the body's full range of motion should be strongly encouraged among all clients that are able to do so and passive or assisted range of motion should be provided to the client when they are not able to perform these exercises on their own. These exercises maintain the body's ability to remain strong and mobile. Routine stretching of the shoulders, neck, arms, hands, and fingers should also be encouraged.
Nurses must implement seizure precautions for at-risk clients to protect them from injury. Seizures, which can be a primary diagnosis or a condition that results from another medical condition such as hypoglycemia, increased intracranial pressure and cerebrovascular accidents, result from abnormal electrical activity in the brain.
Some of the risk factors that can place a client at risk for seizures include:
- Alzheimer's disease
- The use of illicit drugs
- Some prescription drugs
- An overdose of an illicit drug
- A personal history of prior seizures
- A family history of seizures
- Cerebral tumors and infections
- Alcohol withdrawal
- Hepatic failure
- Renal failure
- Exposures to toxins
- Extreme stress
- Some diseases such as syphilis, sickle cell anemia, Whipple's disease etc.
- Abnormal hormonal changes
The client is assessed for the presence of any seizure risk factors and when a seizure disorder is suspected the client will receive diagnostic tests such as an electroencephalogram (EEG) to assess the client's electrical activity of the brain and to determine whether or not epilepsy is the cause of the seizure activity, a MRI and CT scan to determine if there are any structural brain abnormalities like a tumor, a lumbar puncture to determine whether or not the client has an infection or cerebral bleeding, and PET imaging to determine the specific location that is causing the seizure activity.
Most seizures are short lived and they typically persist for only a few minutes; when seizures last more than 3 or 5 minutes they can be life threatening. It is also potentially life endangering when a client has several seizures in rapid succession.
When a seizure is witnessed by the nurse, the nurse must remain with the client, call for the help and assistance of others, and observe and assess the client's physical status, like their cardiac and respiratory functioning, and also implement emergency measures when they are indicated. The client should also be protected from physical injury during the seizure.
All observations and assessments of the client prior to the seizure, such as an aura, during the seizure and after the seizure are fully documented. It is also reported to the client's physician.
Clients who are at risk for seizures and a seizure disorder should be taught and educated about the need to avoid hazardous activities such as climbing to high heights with a ladder because a seizure can occur suddenly and without any warning, the warning signs of a seizure, the risk factors associated with seizures, and to wear a medical emergency tag or bracelet that alerts others to the fact that the person has a seizure disorder.
In addition to more frequent monitoring, clients with a cognitive impairment should be placed in a room near a hub of activity near the nursing station, for example, to prevent injuries and accidents.
Proper patient identification must be done before anything is done for or with a patient. As we previously discussed, accurate identification is necessary during all aspects of nursing care. At least two unique identifiers, other than room number, must be used.
Some examples of unique identifiers include a unique code number, the person’s first, middle and last name and/or complete date of birth including year, an encoded bar code bracelet with at least two unique identifiers imbedded into it and a photograph. Room numbers are never used as unique identifiers. Patients and residents often enter the rooms of other patients and residents, particularly when they are confused.
Patients at greatest risk for identification errors are patients who are confused, comatose, have a primary language other than English, and those patients who have an identical name or a similar name to another patient in the health care facility. For example, Mr. Smith and Mr. Smyth are at risk for identification errors when they are in the same facility.
The proper identification of patients prevents many medical errors, including wrong patient surgery, medication errors and the provision of incorrect treatments and procedures to a patient.
Health care facilities have formalized policies, procedures and mechanisms for patient identification. In addition to the use of two unique identifiers, some health care facilities also have bar coded patient identification bands, patient identification wrist bands that include any patient allergies and even wristbands to alert staff that the client is a do not resuscitate client.
An essential component of injury and accident prevention, as previously detailed with the section above entitled "Identifying and Verifying Prescriptions for Treatments That May Contribute to An Accident or Injury, Not Including Medications", nurses must not only identify and verify all treatment orders and prescriptions to insure that they are not placing the client at risk for any injury or accident and also to verify that the order is appropriate for the client and that it is accurate and transcribed in an accurate manner.
When the nurse receives an order or prescription for a treatment or procedure that is questionable in terms of client appropriateness and safety, the nurse as the nurse manager of care, contacts the person who has prescribed the treatment or procedure, and they also clarify and verify all questionable orders.
- Accident/Error and Incident Prevention (Currently here)
- Emergency Response Plans
- Ergonomic Principles
- Handling Hazardous and Infectious Materials
- Home Safety
- Reporting Incident/Event/ Irregular Occurrence/Variances
- Safe Use of Equipment
- Security Plans
- Standard Precautions/Transmission Based Precautions/Surgical Asepsis
- Use of Restraints/Safety Devices