Maintaining a safe environment refers to the precautions and considerations required to ensure that physical environments are safe for clients and staff. QS​​​​​​​

Knowing how to maintain client safety has been identified by the Institute of Medicine as a competency that graduates of nursing programs must possess.

Common errors in health care are related to medication errors, errors related to diagnostic testing, surgical errors, health care–acquired infection, and errors in hand-off reporting and care.

Quality and Safety Education for Nurses (QSEN) proposes that nursing education focus not only on the knowledge needed to provide safe care but also on the skills and attitudes that accompany this competency.

To maintain a safe environment, nurses must have knowledge, skills, and attitudes about QSEN competencies, handling infectious and hazardous materials, safe use of equipment, accident and injury prevention, home safety, and ergonomic principles.

• A culture of safety is one that promotes openness and error reporting. Developing a culture of safety often results in a lower number of adverse events.
• Facilities should have a risk management department to help identify hazards, prevent adverse events, track the occurrence of negative client incidents, and manage hazards.
• There are several types of events that are reported and tracked under risk management programs.

Service occurrences relate to client services and can include a slight delay in service or an unsatisfactory service.

Near misses are situations where a negative outcome (an accident, illness, or injury) almost occurs.

Serious incidents include minor injuries, loss of equipment or property, or a significant service interruption.

Sentinel events refer to unexpected death, major physical or psychological injury, or situations where there was a direct risk of either of these. Major investigation is required in the case of sentinel events. Sentinel events are classified as one of the following occurring within the facility.

• Major loss of function or death that was not expected with the client’s medical condition
• Client-attempted suicide during round-the-clock care, hemolytic transfusion reaction, wrong site or wrong client surgical procedures, rape, infant abduction, or discharge to the wrong family

Failure to rescue is the most severe type of event and describes a situation where the client develops a complication that leads to death. In failure to rescue situations, there were client indicators that were missed by one or more health care personnel that indicated that a complication was occurring.

Concern about the quality and safety of health care in the U.S. has prompted numerous reports and initiatives designed to address this issue. Data from The Joint Commission identify poor communication as a key factor in many sentinel events. The Institute of Medicine (IOM) report “To Err is Human: Building a Safer Health System” (1999) spoke to the frequency of unnecessary deaths and preventable medical errors and identified system failure as a major factor. Subsequent publications pointed to the need to redesign the provision of client care and improve education of students in health care programs.

The QSEN project identified specific competencies to include in each prelicensure nursing curriculum. These six competencies are now integral components of the curricula of many nursing programs in the United States.

• QPCC Patient-Centered Care: The provision of caring, compassionate, culturally sensitive care that addresses clients’ physiological, psychological, sociological, spiritual, and cultural needs, preferences, and values
• QTC Teamwork and Collaboration: The delivery of client care in partnership with multidisciplinary members of the health care team to achieve continuity of care and positive client outcomes
• QEBP Evidence-Based Practice: The use of current knowledge from research and other credible sources on which to base clinical judgment and client care
• QQI Quality Improvement: Care-related and organizational processes that involve the development and implementation of a plan to improve health care services and better meet clients’ needs
• QS Safety: The minimization of risk factors that could cause injury or harm while promoting quality care and maintaining a secure environment for clients, self, and others
• QI​​​​​​​ Informatics: The use of information technology as a communication and information-gathering tool that supports clinical decision-making and scientifically based nursing practice

Handling infectious and hazardous materials refers to infection control procedures and to precautions for handling toxic, radioactive, or other hazardous materials. QS

Safety measures are taken to protect the client, nurse, and other personnel and individuals from harmful materials and organisms.

Infection control is extremely important to prevent cross-contamination of communicable organisms and health care–associated infections.

• Staff education on infection prevention and control is a responsibility of the nurse.
• Facility policies and procedures should serve as resources for proper implementation of infection prevention and control.
• Any client who is suspected of having or is known to have a communicable disease should be placed in the appropriate type of isolation. 
• The nurse should ensure that appropriate equipment is available and that isolation procedures are properly carried out by all health care team members.
• Use of standard precautions by all members of the health care team should be enforced. Employees should have non-latex gloves (nitrile or vinyl) made available to them. Facilities avoid the use of latex products to eliminate the risk of allergic reactions related to latex allergies.
• Facilities should provide resources for employees to perform hand hygiene in client care areas.
• Health care team members should use securely tied, moisture-resistant bags for disposing of soiled items. To remain cost-effective, items should only be double-bagged if the outside of a bag becomes contaminated.
• The nurse should use safety needles or needle-less IV systems to prevent client and staff injuries from improper manipulation. QS
• The nurse should dispose of biomedical waste in sharps containers immediately after use.
• If a needlestick occurs, the nurse should report it to facility risk management in accordance with facility policy and state law. An incident or occurrence report should also be filed. Most policies include testing of the client and nurse for bloodborne illnesses (e.g., hepatitis and human immunodeficiency virus [HIV]).
• Four levels of precautions (standard, airborne, droplet, contact) are recommended for individuals who come into contact with clients carrying infectious organisms. Precautions consistent with the infectious organism should be followed as indicated.
• Members of the health care team must clean and maintain equipment that is shared by clients on a unit (e.g., blood pressure cuffs, thermometers, pulse oximeters).
• The health care team should keep designated equipment in the rooms of clients who are on contact precautions.

• Nurses and other members of the health care team are at risk for exposure to hazardous materials.
• Employees have the right to refuse to work in hazardous working conditions if there is a clear threat to their health.
• Health care team members should follow occupational safety and health guidelines as set by the Occupational Safety and Health Administration (OSHA).
  • Provide each employee a work environment that is free from recognized hazards that can cause or are likely to cause death or serious physical harm.
  • Make protective gear accessible to employees working under hazardous conditions or with hazardous materials (e.g., antineoplastic medications, sterilization chemicals).
  • Provide measurement devices such as dosimeters and keep records that document an employee’s level of exposure over time to hazardous materials (e.g., radiation from x-rays).
  • Provide education and recertification opportunities to each employee regarding rules and regulations for handling hazardous materials.
  • Provide a manual containing safety data sheets (SDSs) to every workplace and provide safety information (level of toxicity, handling and storage guidelines, and first aid and containment measures to take in case of accidental release of toxic, radioactive, or other dangerous materials). This manual should be available to all employees and can be housed in a location such as the emergency department of a hospital.
  • Designate an institutional hazardous materials (HAZMAT) response team that responds to hazardous events.

Safe use of equipment refers to the appropriate operation of health care–related equipment by educated staff. Equipment-related injuries can occur as a result of malfunction, disrepair, or mishandling of mechanical equipment. QS​​​​​​​

• Learning how to use and maintaining competency in the use of equipment
• Checking that equipment (e.g., oxygen delivery, nasogastric suction) is accurately set and functioning properly at the beginning of and during each shift
• Ensuring that electrical equipment is grounded (three-pronged plug and grounded outlet) to decrease the risk for electrical shock
• Ensuring that outlet covers are used in environments with individuals who are at risk for sticking items into outlets
• Unplugging equipment using the plug, not the cord, to prevent bending the plug prongs, which increases the risk for electrical shock
• Ensuring that life-support equipment is plugged into outlets designated to be powered by a backup generator during power outages
• Disconnecting all electrical equipment prior to cleaning
• Ensuring that all pumps (general and PCA) have free-flow protection to prevent an overdose of fluids or medications
• Ensuring that outlets are not overcrowded and that extension cords are used only when necessary (If they must be used in an open area, tape the cords to the floor.)
• Using all equipment only as it is intended
• Ensuring that equipment is regularly inspected by the engineering or maintenance department and by the user prior to use. Faulty equipment (e.g., frayed cords, disrepair) can start a fire or cause an electrical shock and should be removed from use and reported immediately per agency policy.

• Preventing injury is a significant nursing responsibility.
• Many factors affect a client’s ability to protect themselves. QS
  • Age (pediatric and older adult clients are at greater risk)
  • Mobility
  • Cognitive and sensory awareness
  • Emotional state
  • Lifestyle and safety awareness 
• Review facility protocol for managing specific high-risk situations.

Prevention of client falls is an important nursing priority. Screen all clients for risk factors related to falls.

• Physiological changes associated with aging (decreased strength, impaired mobility and balance, endurance limitations, decreased sensory perception) can increase the risk of injury for some older adults. G
• Other risk factors include decreased visual acuity, generalized weakness, orthopedic problems (diabetic neuropathy), urinary frequency, gait and balance problems (Parkinson’s disease, osteoporosis, arthritis), and cognitive dysfunction. Adverse effects of medications (orthostatic hypotension, drowsiness) also can increase the risk for falls.
• Clients are at greater risk for falls when multiple risk factors are present, and clients who have fallen previously are at risk for falling again.
• To evaluate incidence of client falls, a formula based on 1,000 client days can be used. Using this formula, a facility can compare its fall rates to other facilities.

(Number of client falls ÷ number of client days) × 1,000 = fall rate per 1,000 client days

Prevention of Falls QS​​​​​​​

The plan for each client is individualized based on the fall risk assessment findings.

• Ensure that clients understand how to use all assistive devices and can locate necessary items.
• Place clients at risk for falls near the nurses’ station.
• Ensure that bedside tables, overbed tables, and frequently used items (telephone, water, tissues, call light) are within the client’s reach.
• Maintain beds in low position.
• Keep bed rails up for clients who are sedated, unconscious, or otherwise compromised, and partly up for other clients.
• Avoid using full side bed rails for clients who get out of bed or attempt to get out of bed without assistance.
• Provide clients with nonskid footwear.
• Keep the floor free from clutter with a clear path to the bathroom (no scatter rugs, cords, furniture).
• Ensure adequate lighting.
• Lock wheels on beds, wheelchairs, and carts to prevent the devices from rolling during transfers or stops.
• Use chair or bed sensors to alert staff of independent ambulation for clients at risk for getting up unattended.

Seizures can occur at any time during a person’s life and can be caused by epilepsy, fever, or a variety of other medical conditions.

Seizure precautions (measures to protect the client from injury should a seizure occur) are taken for clients who have a history of seizures that involve the entire body or result in unconsciousness. QS

Protective measures for clients who are at high risk for a seizure include the following.

• Assign the client a room close to the nurses’ station and insert a peripheral IV.
• Ensure that rescue equipment, including oxygen, an oral airway, and suction equipment, is at the bedside. A saline lock can be placed for intravenous access if the client is at high risk for experiencing a generalized seizure.
• Instruct the client to use precautions such as avoiding possible seizure triggers when out of bed.
• If a seizure occurs, provide monitoring and treatment as indicated. See Fundamentals Chapter 12: Client Safety.

Seclusion and restraints are used to prevent clients from injuring themselves or others. For more about restraints, see Fundamentals Chapter 12: Client Safety.

• Seclusion is the placement of a client in a private and safe room. Seclusion is used for clients who are at risk for injuring themselves or others.
• Physical restraint involves the application of a device that limits the client’s movement. A restraint can limit the movement of the entire body or a body part.
• Chemical restraints are medications given to a client whose behavior poses a safety risk to themselves or others.

Risks Associated with Restraints QS​​​​​​​

• Deaths by asphyxiation and strangulation have occurred with restraints. Many facilities no longer use a vest restraint for that reason.
• The client can also experience complications related to immobility (pressure injuries, urinary and fecal incontinence, pneumonia).

• Nurses should understand agency polices as well as federal and state laws that govern the use of restraints and seclusion.
• False imprisonment means the confinement of a person without their consent. Improper use of restraints can subject the nurse to charges of false imprisonment.

• Use restraints according to the prescription parameters, for the shortest time necessary. Attempt early release if the client behavior is calm.
• Restraints are for the protection of clients or others, after all other less restrictive methods of behavior modification have been tried.
• The client or family might have a range of emotions surrounding the use of restraints. Explain the purpose of the restraint and that the restraint is only temporary.
• PRN prescriptions for restraints are not permitted.
• The treatment must be prescribed by the provider based on a face-to-face assessment of the client. In an emergency in which there is immediate risk to the client or others, the nurse can place a client in restraints. The nurse must obtain a prescription from the provider as soon as possible in accordance with agency policy (usually within 1 hr). 
• The prescription must specify the reason for the restraint, the type of restraint, the location of the restraint, how long the restraint can be used, and the behaviors demonstrated by the client that warrant use of the restraint.
• In medical facilities, the prescription should be limited to 4 hr of restraints for an adult, 2 hr for clients age 9 to 17 years, and 1 hr for clients younger than 9 years of age. For adult clients who have violent or self-destructive behavior, the prescription should be for 4 hr. Providers can renew these prescriptions with a maximum of 24 consecutive hours.

Obtain a prescription from the provider for the restraint. If the client is at risk for harming self or others and a restraint is applied prior to consulting the provider, ensure that notification of the provider occurs in accordance with facility protocol. QS

• Conduct neurosensory checks every 2 hr or according to facility policy. These include the following:

  • Circulation
  • Sensation
  • Mobility

• Offer food and fluids.
• Provide with means for hygiene and elimination.
• Monitor vital signs.
• Provide range of motion of extremities.
• Follow agency polices regarding restraints, including the need for signed consent from the client or guardian.
• Review the manufacturer’s instructions for correct application.
• Remove or replace restraints frequently.
• Pad bony prominences.
• Secure restraints (according to facility policy and procedure) to a part of the bed frame that can raise or lower when the bed controls are used.  Do not secure restraints to the siderails of the bed.
• If restraints with a buckle strap are not available, use a quick-release knot to tie the strap.
• Ensure that the restraint is loose enough for range of motion and has enough room to fit two fingers between the device and the client.
• Regularly assess the need for continued use of restraints.
• Never leave the client unattended without the restraints.
• Document client data before, during, and after restraint use, as well as behavioral interventions and care measures.

Fires in health care facilities are usually due to problems related to electrical or anesthetic equipment. Unauthorized smoking can also cause a fire.

All staff must meet the following requirements:

• Know the location of exits, alarms, fire extinguishers, and oxygen turnoff valves.
• Make sure equipment does not block fire doors.
• Know the evacuation plan for the unit and the facility.

Fire response follows the RACE sequence QS​​​​​​​

R: Rescue and protect clients near the fire by moving them to a safer location. Clients who are ambulatory can walk independently to a safe location.

A: Activate the facility’s alarm system and then report the fire’s details and location.

C: Confine the fire by closing doors and windows and turning off any sources of oxygen and any electrical devices. Ventilate clients who are on life support with bag-valve masks.

E: Extinguish the fire if possible, using the appropriate fire extinguisher.

To use a fire extinguisher, use the PASS sequence.

P: Pull the pin.

A: Aim at the base of the fire.

S: Squeeze the handle.

S: Sweep the extinguisher from side to side, covering the area of the fire.

Class A is for combustibles (paper, wood, upholstery, rags, and other types of trash fires).

Class B is for flammable liquids and gas fires.

Class C is for electrical fires.

Nurses play a pivotal role in promoting safety in the client’s home and community. Nurses often collaborate with the client, family, and members of the interprofessional team (social workers, occupational therapists, physical therapists) to promote client safety. QTC

When the client demonstrates factors that increase the risk for injury (regardless of age), a home hazard evaluation should be conducted by a nurse, physical therapist, and/or occupational therapist. The client is made aware of the environmental factors that can pose a risk to safety and suggested modifications to be made.

​​​​​​​Many factors contribute to the client’s risk for injury.

• Age and developmental status
• Mobility and balance
• Knowledge about safety hazards
• Sensory and cognitive awareness
• Communication skills
• Home and work environment
• Community
• Medical and pharmacological status

To initiate a plan of care, the nurse must identify risk factors using a risk assessment tool and complete a nursing history, physical examination, and home hazard appraisal.

• The age and developmental status of the client create specific safety risks. QPCC
• Infants and toddlers are at risk for injury due to a tendency to put objects in their mouths and hazards encountered while exploring their environment.
• Preschool- and school-age children often face injury from limited or underdeveloped motor coordination.
• Adolescents’ risks for injury can stem from increased desire to make independent decisions and relying on peers for guidance rather than family.
• Some of the accident prevention measures for specific age groups are found below. See Fundamentals Chapter 13: Home Safety for age-specific safety recommendations.

Aspiration

• Keep all small objects out of reach.
• Cut or break food that is age-appropriate into small, bite-size pieces.
• Do not place the infant in the supine position while feeding or prop up the infant’s bottle.

Water Safety

• Never leave an infant or toddler unattended in the bathtub.
• Block access to bathrooms, pools, and other standing water.
• Begin teaching water safety when developmentally appropriate.

Suffocation

• Follow recommendations for safe sleep environment and positioning for infants.
• Keep latex balloons and plastic bags away from infants and toddlers.
• Teach caregivers cardiopulmonary resuscitation (CPR) and the Heimlich maneuver.

Poisoning

• Keep houseplants and cleaning agents locked away and out of reach.
• Inspect for and remove hazardous chemicals, medications, and sources of lead from the infant’s or toddler’s environment.

Falls

• Prevent falls from cribs, high beds, diaper changing surfaces, stairs, and windows.
• Supervise when in a highchair, swing, stroller, or similar device and restrain according to manufacturer’s recommendations. Discontinue use when the infant or toddler outgrows size limits.

Motor Vehicle Injury

• Follow car seat requirements based on height, weight, and age.
• Follow recommendations for choosing a safe car seat, and always place it in the back seat.

Burns

• Supervise the use of faucets and test water temperature.
• Keep matches, lighters, and electrical equipment and sources out of reach.

Drowning

• Be sure the child has learned to swim and knows rules of water safety.
• Prevent unsupervised access to pools or other bodies of water.
• Teach the child to wear a life jacket in boats.

Motor Vehicle Injury

• Follow recommendations for car seat use and placement.
• Use seat belts properly after booster seats are no longer necessary.
• Use protective equipment when participating in sports, riding a bike, or riding as a passenger on a bike.
• Teach the child safety rules of the road.

Firearms

• Keep firearms unloaded, locked up, and out of reach.
• Teach the child to never touch a gun or stay at a friend’s house where a gun is accessible.
• Store bullets in a different location from guns.

Play Injury

• Ensure that play equipment is the appropriate size for the child.
• Teach the child to play in safe areas and to avoid heavy machinery, railroad tracks, excavation areas, quarries, trunks, vacant buildings, and empty refrigerators.
• Teach the child to avoid strangers, and keep parents informed of strangers.

Burns

• Teach the child about the dangers of playing with matches, fireworks, and firearms.
• Teach the school-age child how to properly use a microwave and other cooking instruments.

Poison

• Teach the child about the hazards of alcohol, cigarettes, and prescription, non-prescription, and illegal substances.
• Keep potentially dangerous substances out of reach.
• Teach parents to have the nationwide poison control number near every phone in the home and programmed in each cell phone (1-800-222-1222). QS 

Motor Vehicle Injury

• Ensure that the teen has completed a driver’s education course.
• Set rules on seat belt use, the number of people allowed to ride in a car, and calling for a ride home if a driver is impaired.
• Reinforce safety precautions for sports and hobbies.
• Teach water safety.

Burns

• Instruct the teen to use sunblock and protective clothing.
• Discuss the dangers of sunbathing and tanning beds.

Other Risks

• Be alert to indications of depression, anxiety, or other behavioral changes.
• Educate the teen on the hazards of smoking, alcohol, legal and illegal substances, and unprotected sex.
• Discuss dangers of social networking and the Internet.

Motor vehicle crashes are a leading cause of death and injury to adults. Occupational injuries contribute to the injury and death rate of adults. High consumption of alcohol and suicide are also major concerns for adults.

• Follow recommendations for safe alcohol consumption.
• Be attuned to behaviors that suggest the presence of depression or thoughts of suicide. Seek counseling or contact a provider.
• Be proactive about safety in the workplace and in the home.
• Be aware of hazards associated with networking and the Internet.
• Protect skin with the use of sun-blocking agents and protective clothing.

• Many older adults can maintain a lifestyle that promotes independence and the ability to protect themselves from safety hazards.
• Prevention is important because older adult clients can have longer recovery times from injuries and are at an increased risk for complications from injuries.

• The rate at which age-related changes occur varies greatly among older adults. G
• Physical, cognitive, and sensory changes.
• Changes in the musculoskeletal and neurological systems.
• Impaired vision and/or hearing.
• Ambulating frequently at night because of nocturia and incontinence.
• History of a previous fall.

• Remove items that could cause the client to trip (e.g., throw rugs).
• Provide assistive devices and safety equipment.
• Ensure that lighting is adequate inside and outside the home.

• Keep emergency numbers near the phone for prompt use in the event of an emergency of any type.
• Develop a family plan for evacuating the home and practice it regularly.

• Additional risks in the home and community include fires, passive smoking, carbon monoxide poisoning, and food poisoning. Natural and human-made disasters are a threat to homes and communities. Nurses should teach clients about the dangers of these additional risks.

Home fires continue to be a major cause of death and injury for people of all ages. Nurses should educate clients about the importance of a home safety plan.

• Ensure that the number and placement of fire extinguishers and smoke alarms are adequate and that they are operable.
• Be sure to close windows and doors if able.
• Exit a smoke-filled area by covering the mouth and nose with a damp cloth and getting down as close to the floor as possible.
• If the clothing or skin is on fire, “stop, drop, and roll” to extinguish the fire.

If oxygen is used in the home, oxygen safety measures should be reviewed. Oxygen can cause materials to combust more easily and burn more rapidly, so the client and family must be provided with information on use of the oxygen delivery equipment and the dangers of combustion.

• Use and store oxygen equipment according to the manufacturer’s recommendations.
• Place a “No Smoking” sign in a conspicuous place near the front door of the home. A sign can also be placed on the door to the client’s bedroom. QS
• Inform the client and family of the danger of smoking in the presence of oxygen. Family members and visitors who smoke should do so outside the home.
• Ensure that electrical equipment is in good repair and well grounded.
• Replace bedding that generates static electricity (wool, nylon, synthetics) with items made from cotton.
• Keep flammable materials (e.g., heating oil, nail polish remover) away from the client when oxygen is in use.
• Follow general measures for fire safety in the home (having a fire extinguisher readily available and an established exit route) should a fire occur.

Passive smoking (secondhand smoke) is the unintentional inhalation of tobacco smoke.

• Exposure to nicotine and other toxins places people at risk for numerous diseases, including cancer, heart disease, and lung infections.
• Low birth weight, prematurity, stillbirths, and sudden infant death syndrome (SIDS) have been associated with maternal smoking.
• Passive smoking is associated with childhood development of bronchitis, pneumonia, and middle ear infections.
• For children who have asthma, exposure to passive smoke can result in an increase in the frequency and severity of asthma attacks.

Nursing actions

• Inform clients about the hazards of smoking and exposure to smoke from cigarettes, cigars, and pipes. The effects of vapors from electronic cigarettes is unclear. QEBP
• Discuss resources to stop smoking (smoking-cessation programs, medication support, self-help groups).

• Carbon monoxide is a very dangerous gas because it binds with hemoglobin and ultimately reduces the oxygen supplied to tissues in the body.
• Carbon monoxide cannot be seen, smelled, or tasted.
• Indications of carbon monoxide poisoning include nausea, vomiting, headache, weakness, and unconsciousness.

Client education

• Ensure proper ventilation when using fuel-burning devices (lawn mowers, wood-burning and gas fireplaces, charcoal grills).
• Have gas-burning furnaces, water heaters, chimneys, flues, and appliances inspected annually.
• Flues and chimneys should be unobstructed.
• Install and maintain carbon monoxide detectors.

• Most food poisoning is caused by bacteria (Escherichia coli, Listeria monocytogenes, salmonella).
• Infants, toddlers, older adults, pregnant individuals, and immunocompromised individuals are at risk for complications.
• Clients who are especially at risk are instructed to follow a low-microbial diet.

Measures to prevent food poisoning

• Proper hand hygiene
• Ensuring that eggs, meat, and fish are cooked to the correct temperature
• Handling raw and cooked food separately to avoid cross-contamination
• Not using the same container, cutting board, or utensils for raw and cooked foods
• Refrigerating perishable items
• Washing raw fruits and vegetables before peeling, cutting, or eating
• Not consuming unpasteurized dairy products or untreated water

• Natural disasters, such a tornadoes and floods, and human-made events (forest fires or explosions) can occur without warning.
• Encourage personal emergency preparedness for clients and families, which includes gathering supplies (food, water, clothing, communication devices, extra medications, and personal documents).

Ergonomics are the factors or qualities in an object’s design and/or use that contribute to comfort, safety, efficiency, and ease of use. QS

• Body mechanics is the proper use of muscles to maintain balance, posture, and body alignment when performing a physical task. Nurses use body mechanics when providing care to clients by lifting, bending, and carrying out the activities of daily living.
• The risk of injury to the client and the nurse is reduced with the use of good body mechanics. Whenever possible, mechanical lift devices should be used to lift and transfer clients. Many health care agencies have “no manual lift” and “no solo lift” policies. 
• See Fundamentals Chapter 14: Ergonomic Principles and Client Positioning for more information.

• Know your agency’s policies regarding lifting.
• Plan for activities that require lifting, transfer, or ambulation of a client, and ask other staff members to be ready to assist at the time planned.
• Maintain good posture and exercise regularly to increase the strength of arm, leg, back, and abdominal muscles so these activities require less energy.
• Use smooth movements when lifting and moving clients to prevent injury through sudden or jerky muscle movements.
• When standing for long periods of time, flex the hip and knee through use of a footrest. When sitting for long periods of time, keep the knees slightly higher than the hips.
• Avoid repetitive movements of the hands, wrists, and shoulders. Take a break every 15 to 20 min to flex and stretch joints and muscles.
• Maintain good posture (head and neck in straight line with pelvis) to avoid neck flexion and hunched shoulders, which can cause impingement of nerves in the neck.
• Avoid twisting the spine or bending at the waist (flexion) to minimize the risk for injury.
• Keep objects close to the body core when lifting and bend the knees to keep the center of gravity closer to the ground.
• When lifting an object from the floor, flex the hips, knees, and back. Get the object to thigh level, keeping the knees bent and straightening the back. Stand up while holding the object as close as possible to the body, bringing the load to the center of gravity to increase stability and decrease back strain.
• Use assistive devices whenever possible and seek assistance whenever it is needed.
• Face the direction of movement when moving a client.
• Use your own body as a counterweight when pushing or pulling, which makes the movement easier. QS​​​​​​​
• Use sliding, rolling, and pushing movements when possible because these require less energy than lifting and have less risk for injury.
• Avoid twisting the thoracic spine and bending the back while the hips and knees are straight.
• Assess the client’s ability to help with repositioning and mobility (balance, muscle strength, endurance).
• Determine the need for additional personnel or assistive devices (transfer belt, hydraulic lift, sliding board, gait belt).

Facility protocols refer to the plans and procedures in place to address specific issues that health care institutions face.

Nurses must understand their role in relation to development and implementation of facility protocols, including reporting incidents, disaster planning, emergency response, and security plans.

Incident reports are records of unexpected or unusual incidents that affected a client, employee, volunteer, or visitor in a health care facility.

• Facilities can also refer to incident reports as unusual occurrence or quality variance reports.
• In most states, if proper safeguards are employed, incident reports cannot be subpoenaed by clients or used as evidence in lawsuits.

Examples of when an incident report should be filed:

• Medication errors
• Procedure/treatment errors
• Equipment-related injuries/errors
• Needlestick injuries
• Client falls/injuries
• Visitor/volunteer injuries
• Threats made to clients or staff
• Loss of property (dentures, jewelry, personal wheelchair)

Nurses must ensure the safety of clients’ valuables. If a client is admitted to the facility and does not have a family member present, secure the client’s valuables in accordance with facility policy. If an individual requests the client’s valuables, the client must identify the person and give that person permission to be in possession of the valuables.

In the event of an incident that involves a client, employee, volunteer, or visitor, the nurse’s priority is to assess the individual for injuries and institute any immediate care measures necessary to decrease further injury. If the incident was client-related, notify the provider and implement additional tests or treatment as prescribed. QS

• Should be completed by the person who identifies that an unexpected event has occurred (This might not be the individual most directly involved in the incident.)
• Should be completed as soon as possible and within 24 hr of the incident
• Considered confidential and are not shared with the client (Nor is it acknowledged to the client that one was completed.)
• Not placed nor mentioned in the client’s health care record (However, a description of the incident should be documented factually in the client’s record.)
• Include an objective description of the incident and actions taken to safeguard the client, as well as assessment and treatment of any injuries sustained
• Forwarded to the risk management department or officer (varies by facility), possibly after being reviewed by the nurse manager
• Provide data for performance improvement studies regarding the incidence of client injuries and care-related errors QQI​​​​​​​

When completing an incident report, include:

• Client’s name and hospital number (or visitor’s name and address if visitor injury), along with the date, time, and location of the incident
• Factual description of the incident and injuries incurred, avoiding assumptions as to the incident’s cause
• Names of witnesses to the incident and client or witness comments regarding the incident
• Corrective actions that were taken, including notification of the provider and referrals
• Name and dose of any medication or identification number of any equipment involved in the incident