Learning Objectives
By the end of this section, you will be able to:
- Identify safety concerns regarding the individual
- Identify safety concerns related to the environment
- Recognize how social determinants of health relate to one’s safety
Nurses play a pivotal role in ensuring the safety and well-being of patients, as well as their own personal safety. In health care, there are many potential hazards and risks that can threaten patient safety, including medical errors, falls, infections, and medication errors. Similarly, these hazards may exist in the homes of patients and the environments in which we live and work. Nurses must be knowledgeable about these risks and take proactive measures to prevent them. Additionally, nurses are responsible for maintaining their own physical and emotional health, as they are often exposed to high levels of stress and emotional strain in their work. In this way, safety and health are intertwined, and nurses must prioritize both in their daily practice.
Choices and actions regarding safety can be influenced by many factors; this might include situations we are in, where we live, our income, and our education. These factors are known as the social determinants of health (SDOH). This section explores various aspects of individual safety and the tools nurses need to use to respond to safety concerns.
Individual Safety
Safety is a basic human need and always receives priority in patient care. In prioritizing patient needs, nurses refer to Maslow’s hierarchy of needs (Figure 9.2), often concentrating on the lower two tiers of the pyramid, as security is closely linked with basic physiological requirements.
Consider the following scenario: You are driving back from a relaxing weekend at the lake and come upon a fiery car crash. You run over to the car to help anyone inside. When you get to the scene, you notice that the lone person in the car is not breathing. Your priority is not to initiate rescue breathing inside the burning car but to move the person to a safe place where you can safely provide CPR. This is an illustration of how safety is intertwined with nursing care.
The term individual safety can be defined as the state of being free from physical or psychological harm. Individual safety is a fundamental concern across the life span. Individual safety concerns are unique to each developmental stage and are influenced by many different factors, including individual differences, environmental factors, and cultural norms. To promote and maintain individual safety, consider the developmental stage of the individual and plan interventions that address safety concerns in a holistic manner. For example, Barbara is an 85-year-old female living alone. Having encountered several falls, her family expresses concern for Barbara’s safety and urges her to consider relocating to an assisted living facility. Barbara wants to remain in her home where she feels safe; there are no concerns regarding her competency to make decisions regarding her care. This is an example of a situation where nurses must balance the developmental needs of the patient within a holistic framework. While Barbara might have experienced a few instances of falling, there are no other indications that she is not safe in her home, and she may only need minimal assistance to maintain her residence. The nurse works to balance the safety of a patient with the patient’s need for independence.
Individual safety encompasses various aspects of safety, such as occupational safety, environmental safety, and personal safety, and all are crucial for maintaining good health:
- The goal of occupational safety is to protect workers from injury, particularly those who work in high-risk industries such as health care. Workplace injuries and illnesses cost U.S. businesses approximately $170 billion per year (Occupational Safety and Health Administration [OSHA], n.d.).
- The practices and measures taken to promote environmental safety are geared to protecting and preserving the natural environment, ecosystems, and human health from potential hazards and harmful impacts to health. Exposure to environmental hazards such as air pollution, water pollution, and hazardous waste can have significant impacts on an individual’s health. For example, one study found that exposure to air pollution is associated with an increased risk of heart disease, stroke, and respiratory illnesses (Landrigan et al., 2018).
- Test one
- Test two
- The goal of personal safety is to keep oneself free from injury. This includes taking measures to prevent accidents and injuries in everyday life, such as wearing seat belts while driving, using protective equipment during sports and recreation, and avoiding risky behaviors such as smoking and drug use.
Personal safety and individual safety, while not synonymous, share similarities. Individual safety pertains to safety measures designed to establish frameworks supporting individuals’ safety, while personal safety is reflected in the choices individuals make to implement safeguards for themselves. For example, as the COVID-19 pandemic waned, masking requirements were loosened; however, there was still recognition of the need to provide guidelines for those who were more at-risk. The guidelines advocating for mask usage in certain situations demonstrate individual safety, whereas personal safety involves the individual’s decision to wear a mask. In nursing, individual safety and occupational safety go hand in hand. The physically demanding nature of nursing work and the exposure to infectious diseases put nurses at a heightened risk of workplace injuries. Individual safety measures adopted by nurses play a crucial role in safeguarding them during the execution of their healthcare duties, ensuring their well-being to continue providing care for patients.
Risk Factors Affecting Individual Safety
Individual risk factors are considered correctable or modifiable because they are often influenced by behaviors, choices, or lifestyle habits that individuals can consciously change or improve. For instance, nurses are advised to wear gloves during tasks involving potential blood exposure. If a nurse is observed not adhering to this practice, education and reinforcement of proper procedure can be implemented to modify their behavior. Individual risk factors frequently contribute to healthcare-related issues. Addressing these individual risk factors is crucial for maintaining an individual’s safety.
Risk factors can fall into two categories: modifiable and nonmodifiable. A modifiable risk factor refers to a factor that can be altered or controlled by an individual or society. Modifiable risk factors include behaviors and lifestyle choices, such as diet, exercise, smoking, alcohol consumption, and exposure to environmental pollutants. They can be modified through education, lifestyle changes, and policy interventions, among other means. A nonmodifiable risk factor, on the other hand, cannot be controlled or altered by an individual or society. Nonmodifiable risk factors include genetic predispositions, age, gender, and certain geographical and climatic conditions. These factors are beyond an individual’s control and may be inherent or innate, making them less responsive to intervention. In general, modifiable risk factors tend to be more responsive to intervention and change, whereas nonmodifiable risk factors require a different approach to manage their impact on one’s health.
Age and Developmental Considerations
Age and developmental factors play a crucial role in individual safety, influencing an individual’s ability to comprehend and respond to potential hazards. Nurses should be knowledgeable about safety risks associated with age and developmental stages, as the types and frequencies of accidents vary among different age groups (Centers for Disease Control and Prevention [CDC], 2020a).
Regardless of a person’s age or developmental stage, nurses must be ready to discuss mental health, family, and social connections with every patient. Nurses can prepare for these conversations by having community resource information readily available to direct any patient in need to the right entity for help. Nurses do not have all the answers, but they should always be knowledgeable about where to refer patients for help.
Children
Drowning is the leading cause of death in children ages 1 to 3 years. Motor vehicle accidents (Figure 9.3), falls, choking, and accidental poisoning are also safety concerns for this age group. Infants and toddlers are curious, but they lack the judgment to recognize the dangers of their actions, so childproofing the home and providing adult supervision are essential for this developmental age group (CDC, 2023c).
For children ages 4 to 11 years, motor vehicle injuries are a major cause of unintentional injury, along with drowning and poisoning. This age group is more aware of dangers and limitations, but adult supervision is still important. The nurse should educate parents of school-aged children about safety seats, booster seats, or shoulder seat belts while riding in the car (CDC, 2023c). Bicycle accidents are also a common concern in this age group. Many bicycle accidents involve the head or face because of the lack of helmet use. Nurses should provide education to school-aged children regarding bicycle safety and helmet use (Figure 9.4).
Link to Learning
The CDC provides educational materials and comprehensive information about concussion and traumatic head injuries for parents, coaches, players, and healthcare providers as part of their “Heads Up” program.
Because this age group is beginning to enjoy more independence, education on how to recognize and respond to potentially dangerous situations with strangers should also be provided. Parents should also be educated about the AMBER Alert system that can be activated if a child is missing and believed to be kidnapped or in danger. The AMBER Alert system uses the resources of law enforcement and the media to notify the public about a possible abduction or a missing child in danger.
Nurses must also be aware of signs of maltreatment and child abuse because millions of children are affected each year. Child abuse includes physical, sexual, and emotional abuse and neglect. After abuse or violence, many children develop mental health problems, including depression and post-traumatic stress disorder (American Academy of Child and Adolescent Psychiatry [AACAP], 2021). These children may also have serious medical problems, learning problems, and problems getting along with friends and family members. Every state has laws that require healthcare professionals to report suspected child abuse no matter what form this abuse takes (AACAP, 2021).
Link to Learning
Read more about trauma and child abuse within the Trauma and Child Abuse Resource Center provided by AACAP.
Children between the ages of 6 to 11 years are often an at-risk group when it comes to safety, as they are not yet fully developed physically, mentally, or emotionally and have a greater risk of accidents such as drowning, burns, poisoning, or other injuries. These risks may occur in the form of accidents or sports injuries at home, at school, or in their communities. Children in this age group are more likely to experience social issues such as bullying, peer pressure, and some forms of social exclusion. They are also at risk for physical and emotional abuse in the home, and this needs to be considered when performing assessments. These can be difficult safety concerns to manage as the child may be reluctant to discuss these issues, and early indicators for parents and caregivers may come in the form of behavior changes.
Nurses must take a role in educating parents and caregivers about safety protection for children. It is important for parents and caregivers to take appropriate precautions to protect children, such as supervising them, teaching them about safety, and providing a safe physical environment, along with addressing bullying and any suspicions of abuse.
Adolescents
Motor vehicle accidents are a leading cause of death for adolescents. Teens ages 16 to 19 years are three times more likely to be in a fatal crash than drivers older than age 20 years. Adolescent males are twice as likely to die in a motor vehicle accident than females of the same age (CDC, 2023c). Texting while driving is a common cause of distracted driving and accidents in adolescents. Because much of an adolescent’s time is spent away from home, it is difficult for parents to control many of the decisions that adolescents make. Nurses can assist in providing safety education to adolescents by teaching them how and why we use seat belts, why speed limits must be obeyed, and why they should never text while driving (CDC, 2023c). Substance use is another significant concern in the adolescent population and is discussed in 9.2 Safety: Violence.
Life-Stage Context
Risk-Taking Behaviors of Young People
It is said that the young often feel they are invincible. As a result, they may make choices that are not in their best interests to “fit in” with their peers. Adolescents lack developed judgment skills at this age and tend to engage in risk-taking behaviors, for example, smoking and trying alcohol or drugs. Adolescents may take risks when performing activities such as skateboarding. Often, they fail to grasp the significance of potential negative outcomes from these activities. This is part of the expected developmental stages for adolescents where they are learning and discovering who they are. This can be difficult for parents and healthcare providers, and it is important to know that adolescents can be encouraged to foster this risk-taking in healthy ways, for example, via activism or athletic endeavors (UCLA Center for the Developing Adolescent, 2023).
Adults
The leading cause of death for adults in the United States is heart disease, followed by cancer and COVID-19 (CDC, 2023b). Being an adult does not mean one is immune to the need to consider individual safety. Adults may still engage in risk-taking behaviors, including the use of substances, that can put them at risk. Adults are also at risk of experiencing workplace injuries, particularly young adults who may just be entering the workforce. Some adults may be at increased risk of hazards related to financial instability and personal safety in relationships and their communities. Adulthood may also be a time when individuals begin to experience life with chronic disease, which can impact safety from a physical, cognitive, or emotional perspective (CDC, 2019a). It is important for adults to consider their individual safety risks and take precautions to maintain good health and be aware of potential risks around them.
Older Adults
Falls and motor vehicle accidents are the leading causes of injury in older adults. However, several other issues pose significant hazards for this population, such as fires, accidental overdosing on medications (due to poor eyesight and confusion), abuse, and being taken advantage of financially (CDC, 2021). Older adults are also at risk for age-related changes, such as mobility changes, that can create a safety risk. Older adults are more likely to live on their own, increasing their vulnerability, whether that be from injury or events such as elder fraud (financial exploitation or deceptive practices specifically targeting older individuals). Older adults living alone are at greater risk of experiencing depression linked to social isolation. Those living alone, especially older adults with dementia, may encounter challenges in maintaining hygiene, nutrition, and household tasks. For instance, a person living with dementia who is not eating may experience the effects of malnutrition (Alzheimer’s Association, n.d.). When assessing an older adult who is living alone, the nurse should ask questions regarding their ability to complete activities of daily living.
Lifestyle and Behavior Considerations
Protecting the body from harm, injury, or death is key to maintaining physical safety. Personal actions taken toward one’s health influences individual safety. Adopting healthy lifestyle practices, such as eating a healthy diet, exercising regularly, getting adequate sleep and rest, and limiting or avoiding the use of drugs and alcohol, has a positive impact on individual safety. Engaging in high-risk activities, such as bicycling without a helmet or driving without wearing a seat belt, can negatively impact safety. Individual safety must also be considered when engaging in local and global community activities. Maintaining infection prevention, following travel precautions, and proactive planning safeguards individual health and contributes to the overall well-being of communities, thereby minimizing the risk of transmitting illnesses.
Link to Learning
The World Health Organization provides information concerning risks when traveling in a question-and-answer format. This website provides travelers with helpful information regarding health and other risks, such as political unrest. Travelers can then take precautions or make decisions regarding planned travel to ensure they remain safe.
Health Knowledge Deficits
A health knowledge deficit is a lack of information or understanding regarding health-related topics that can impact an individual’s ability to make informed decisions about their health and well-being. Such deficits can result in inadequate self-care, inappropriate use of medications, ineffective management of chronic conditions, and poor adherence to medical advice or treatment plans (Berkman et al., 2011). Examples of health knowledge deficits include the following:
- lack of knowledge about healthy lifestyle behaviors, such as proper nutrition, exercise, and stress management
- insufficient understanding of medical conditions, their causes, symptoms, and treatment options
- inadequate knowledge about medications, including their proper use, potential side effects, and interactions with other drugs
- poor understanding of risky health behaviors, such as smoking or excessive alcohol consumption
- insufficient knowledge about preventive measures, such as vaccines, cancer screenings, and regular checkups
- lack of knowledge about where to find accurate, unbiased, and credible health information
Addressing health knowledge deficits is crucial for promoting optimal health outcomes and reducing the risk of chronic diseases and other health problems. This can involve providing education, counseling, and support to individuals, as well as promoting health literacy and patient empowerment.
Individuals with knowledge deficits have unique safety risks to address. Those living with knowledge deficits may be at risk of physical harm due to a lack of understanding related to the actions they take. A patient with a health knowledge deficit may have difficulty understanding health teaching; for example, a patient may not understand they should not get a cast wet because water dissolves the stability of the plaster. Nurses need to assess the patient’s understanding of education. This could include asking the patient to repeat the steps of a procedure back to them or demonstrating how to perform an activity. This is known as a teach-back method, a way for healthcare providers to present information to patients clearly and determine the patients’ understanding of the information (Agency for Healthcare Research and Quality [AHRQ], 2021). The goal is to make sure patients and their families have received and understood important healthcare information. After providing information to the patient and family, the healthcare provider asks them to repeat the information back, in their own words (AHRQ, 2021). This method allows nurses to hear what the patient and family understood and clarify any misinformation. To address knowledge deficit, the nurse must teach the patient what to do and what not to do. In the earlier example of not getting a cast wet, it is possible the patient heard “don’t take a bath.” A better way to prevent misunderstanding is for the nurse to follow “don’t get the cast wet” with “this is how you can shower or take a bath with a cast.” Then, have the patient perform a return demonstration of how they would protect their cast while taking a bath.
Patient Conversations
Diabetes Education
Scenario: Luisa, a 65-year-old female who was recently diagnosed with type 2 diabetes, is admitted to the hospital for uncontrolled blood glucose levels. The nurse walks into the patient’s room to conduct a morning assessment.
Nurse: Good morning, Luisa. How are you feeling today?
Patient: I’m okay, just a bit tired.
Nurse: I understand. I wanted to talk to you about managing your diabetes. Do you have any questions or concerns about your condition?
Patient: Actually, yes. I don’t know much about diabetes or how to manage it.
Nurse: That’s perfectly okay. Diabetes is a complex condition, but with the right education and support, you can manage it effectively. Let’s start with the basics. Do you know what causes diabetes?
Patient: Not really, no.
Nurse: Diabetes occurs when your body can’t produce or use insulin properly. Insulin is a hormone that helps regulate your blood sugar levels. When your body can’t produce enough insulin, or if it can’t use it properly, your blood sugar levels can rise too high. This can cause a range of complications, including damage to your nerves, eyes, and kidneys.
Patient: I see, so what can I do to manage my diabetes?
Nurse: There are a few things you can do. First, you’ll need to monitor your blood sugar levels regularly. This involves testing your blood using a blood glucose meter. We’ll show you how to do this before you leave the hospital. Second, you’ll need to make some changes to your diet. This means reducing your intake of sugar and carbohydrates and increasing your intake of fruits, vegetables, and whole grains. Finally, you’ll need to stay active. Regular exercise can help regulate your blood sugar levels and improve your overall health.
Patient: That all sounds very overwhelming.
Nurse: I understand that it can seem overwhelming at first, but we’re here to support you every step of the way. We’ll provide you with resources and education to help you manage your diabetes effectively. I will bring them next time I come in your room. I will also have our diabetic educator come visit with you later today.
Patient: Thank you, I appreciate your help.
Nurse: Of course, Luisa. We’re here to help you live a healthy and fulfilling life with diabetes. Do you have any other questions or concerns for me?
Patient: No, not currently. I will let you know after we go over the resources you are bringing regarding my food choices, and I will wait for the diabetic educator to come by and visit with me before being discharged. I look forward to learning more about how to better manage my health. Thank you.
Alterations in Physical Health
Health and safety are interrelated aspects of an individual’s life. Health can impact safety, and safety can impact health. A person experiencing physical health challenges may face an increased risk to personal safety because of illness or injury. Changes in one’s ability to perform activities safely on their own may increase risk of injury. For example, a person who now has balance issues and showers without assistance may be at increased risk for a fall.
Side effects from necessary medications which lead to alterations in physical health may also increase one’s risk for injuries or accidents. Some medications are known to cause drowsiness, necessitating a warning label informing those taking it to take care when operating machinery or driving vehicles. Medications, such as those used to treat pain, may also impair an individual’s judgment and response times. It is important for individuals to be aware of any risks associated with medications and to take necessary precautions to prevent injury or accidents.
Life-Stage Context
Narcotic Use and Risk of Falls in Older Adults
The use of certain medications, such as narcotics, is sometimes necessary to manage pain. With aging, there is an increased likelihood of requiring medical interventions like surgery or other treatments. Consequently, narcotics may be prescribed to aid in the recovery process. Narcotics can increase the risk of falls, particularly for older adults; thus, they must be prescribed and used with caution. Patients should be educated regarding their increased fall risk and exercise caution when using these medications (Virnes et al., 2022).
Impaired Mobility
Maintaining individual safety is of particular importance for those living with mobility issues. Impairments can affect an individual’s ability to move safely within their environment and community, making them more susceptible to accidents or injury. The home is often the main place where injury can occur (WHO, 2018). A well-decorated home may have rugs, a lot of furniture, and dim lighting. While attractive, these features increase the risk of falls in compromised patients. To keep oneself safe at home, it is important to do the following:
- Clear pathways going into and around the home to ensure there is no clutter or other tripping hazards, such as loose paving stones.
- Install handrails on stairs both inside and outside of the house to help with stability and prevent falls.
- Install grab bars and nonslip mats in the bathroom to prevent falls.
- Ensure the bed is kept at a reasonable height to make it easy to get in and out.
- Be careful with the use of throw rugs that can be a fall hazard.
Individuals must also consider outdoor safety in their communities. Sidewalks can pose a risk if they are uneven or have cracks or obstacles embedded into their surface. For regions that experience snow and ice, sidewalks can be particularly dangerous to navigate. Those living with mobility issues should consider how they will navigate public transportation to ensure they are utilizing services that are accessible and support their mobility. Individuals living with mobility concerns should communicate with those around them and have a plan in place in case of emergency to ensure their safety.
Life-Stage Context
Mobility Concerns for Older Adults
Mobility becomes more challenging with age, putting older adults at risk for falls. Nurses should observe older patients as they walk into the room to determine any challenges with gait or balance. The nurse should consider utilizing a well-created questionnaire when preparing a patient for discharge. Each question should be clear enough to reveal any possible hazards or barriers to the patients’ mobility and safety when they return home. Simply asking if they have running water and indoor plumbing is not enough. Even patients who are financially privileged can have barriers to mobility and safety. Consider a very successful patient who lives in an affluent historic district. They might not be able to walk safely outside because historic districts tend to have large trees that disrupt the sidewalk or have no sidewalks at all. Nurses must ask clear questions to obtain a clear picture of what the patient will experience when they return home.
Altered Sensory Perception
A vital aspect of functioning in everyday life is sensory perception, defined as the ability to see, hear, touch, taste, and smell. Alterations in sensory perception can have a significant impact on an individual’s ability to navigate their environment. Any changes to these senses create risk for the individual; for instance, a person who cannot smell may not notice the first signs of something burning in their home. Table 9.1 describes some common sensory perception impairments and how to address them.
| Sensory Impairment | Impact | Ways to Address |
|---|---|---|
| Visual impairments, including full or partial blindness | May not have the ability to safely navigate personal and public environments | Using a white guide cane (white indicates blind or visually impaired), guide dogs, or other assistive devices to help with navigation |
| Hearing impairments, including complete or partial deafness | May not hear alarms or the voices of people calling out safety warnings | Using assistive devices, such as hearing aids; having an emergency plan in place to ensure safety |
| Touch impairments, not able to sense or feel changes in temperature | Can create risks for burns and frostbite or other potential hazards in the environment | Monitoring external temperatures and taking measures to protect from extreme temperature changes (e.g., use a thermometer to obtain a water temperature when bathing to prevent burns from hot water) |
| Taste and smell impairments | Impact ability to sense hazards, such as a gas leak or food that has spoiled | Asking a caregiver to smell foods to ensure they are not spoiled; having a trained therapy dog that can detect harmful odors, such as gas leaks in the home |
Alterations in Psychosocial Health
An individual’s psychosocial health refers to the psychological and social aspects of that individual’s overall health and well-being. It encompasses the interplay between a person’s mental health and their relationships with others and the world around them. Psychosocial health is crucial for a person’s overall health, as it impacts their ability to cope with stress, form relationships, and make decisions. A person with good psychosocial health tends to have a positive outlook on life, feel socially connected, and be able to adapt to life’s challenges in a healthy way. Poor psychosocial health can lead to a range of health alterations, encompassing mental health conditions like depression and anxiety, social isolation, substance misuse, and physical health issues such as high blood pressure and heart disease. A lack of social support and poor coping skills can also lead to a higher risk of chronic diseases, such as diabetes and obesity.
Stress
Stress is a natural part of life; we all experience stress at varying points. However, too much stress can create unsafe environments for individuals. Chronic stress can affect an individual’s physical, emotional, and mental well-being, which may decrease their ability to respond to potential hazards or make safe decisions. See Table 9.2 for examples of how different types of stress impact one’s health. An individual living with anxiety may have difficulty completing a task that requires focus and attention, thus leading to increased risk of an accident. Those living with diagnoses such as phobias or depression may find their judgment clouded, making it difficult to adequately access risk.
| Type of Stress | Example | Impact on Individual Safety and Health |
|---|---|---|
| Physical stress | Overexertion |
|
| Mental health stress | Loss of one’s job |
|
| Social or behavioral stress | Loss of an important relationship |
|
To effectively manage one’s psychosocial health to prevent injury, individuals should understand their own response to stress as well as steps they can take to mitigate risk factors. One can manage this by practicing self-care techniques, reducing stress, and addressing the emotional and psychological factors that are harming health. Self-care can include meditation, exercise, yoga, spending time in nature or with friends, and sleep. Remaining healthy from a psychological and emotional perspective also means seeking help and support when needed.
Cognition
The mental processes that enable individuals to think, learn, remember, and make decisions to act are referred to as cognition. Alterations in cognition can result in changes in an individual’s ability to think clearly and act appropriately. Conditions like dementia or mild cognitive impairments can hinder an individual’s ability to recognize potential hazards and make safe decisions, as they may be unaware that their actions pose risks. This is important for caregivers and family members to understand. The patient is not purposely engaging in risky, careless behavior, and their actions do not indicate a lack of intelligence. They are experiencing a change in their mental processes and must be treated with respect while the situation is being resolved. The use of medications like pain relievers and sedatives, intended for pain management or sleep assistance, can negatively impact an individual’s cognitive abilities and judgment. Sleep deprivation, which may occur during illness or if an individual is a caregiver, can impair an individual as much as using substances. Lack of adequate sleep can make it difficult to think clearly and make safe decisions.
Individuals concerned about cognitive changes can take measures to ensure a safe environment. These include getting sufficient sleep and rest, conducting medication reviews with a pharmacist, minimizing or discontinuing use of substances that may impact cognition (e.g., sedatives and narcotics), maintaining open communication with caregivers and family members, and establishing an emergency response plan. Caring for a loved one with dementia can increase stress for caregivers, and in turn, increase the risk of illness for them. Families should seek professional intervention when a loved one is diagnosed with dementia to ensure both the patient and family receive adequate support and services. This may include respite services, providing caregivers with opportunities to take a break and participate in self-care activities. Professional assistance may be required to begin the process of in-home care or long-term placement in a care facility.
Suicide Risk
Suicide is a leading cause of death and a significant public health concern. Most institutions require nurses to complete a suicide risk assessment for all patients, utilizing evidence-based tools to evaluate their potential risk of self-harm (CDC, 2021). For any patient who is at risk of suicide, the nurse must include the patients’ support system and initiate a safety plan. Suicide risk can be influenced by several factors, including mental health conditions, life events, and having access to substances or physical objects that could be used to cause harm. Individuals at risk of suicide may be more likely to engage in risky behaviors due to an underlying mental health crisis.
Environmental Safety
The environment plays a crucial role in health and well-being. Environmental factors such as air quality, water quality, and exposure to hazardous materials can all have a significant impact on individual health. It is important for individuals to be aware of local environmental conditions and concerns and to take the necessary steps to reduce the risks.
The environment can encompass several things: it can be used to describe one’s home and surroundings, a neighborhood, or a work setting. The environment can also describe work settings or the community as well as the land we live on, the water we drink, and the air we breathe. Each of these environmental settings has an impact on individual and collective health. For example, a train derailment may cause the release of toxic chemicals into the land and water surrounding a community. A patient in the suburbs might have access to a walking path through a large park where vehicles are prohibited, while a patient in a more urban area may have to continually cross streets with dangerous traffic. Crime rates and the availability of community support can influence safety; for example, a patient in an area with frequent street crime may feel uncomfortable taking a daily walk or going to the pharmacy. Geography can also impact safety. For example, those living in rural communities may have less access to the infrastructure and resources necessary to remain safe. The geographical remoteness of these areas often results in longer response times for emergency personnel to reach the location of an incident, which may be critical in situations where immediate medical attention or intervention is required. Living in areas where the air quality is poor or where there is a greater risk of natural disasters, such as wildfires or flooding, impacts personal safety.
Factors Affecting Environmental Safety
Environmental factors can be broadly classified into two categories: modifiable and nonmodifiable factors. Modifiable environmental factors are linked to pollution levels and occupational exposure through the influence of individual choices and behaviors. Lifestyle and behavior choices, such as transportation methods, use of energy sources, and adherence to safety practices in the workplace, for instance, can directly impact pollution levels and occupational exposure. These factors can be influenced through various means, including policy interventions, education and awareness campaigns, and personal behavior changes. Nonmodifiable environmental factors, on the other hand, are determined by geography, climate, genetics, and age. Examples of nonmodifiable environmental factors include natural disasters, genetic predisposition to certain diseases, and the age-related decline in immune function. In general, modifiable environmental factors are more responsive to intervention and can be altered to promote health and prevent disease. While some environmental factors, such as exposure to toxic chemicals or infectious agents, can have an acute and immediate impact on our health, others may have more insidious effects that only become apparent over time, such as prolonged exposure to certain environmental factors that lead to chronic diseases and other health problems (Table 9.3).
| Factor | Potential Outcomes | Interventions |
|---|---|---|
| Air quality | Can cause health problems, such as respiratory disease, cardiovascular disease, and cancer. Air pollution or poor ventilation can increase the risk of suffocation. For instance, a person with severe asthma may experience a life-threatening respiratory episode if exposed to an irritant. | Monitor air quality and avoid exposure if the air quality is poor. Individuals with known respiratory disease may require the use of medications to assist in breathing when the air quality is poor and should be educated to stay indoors as much as possible. |
| Water quality | Exposure to contaminated water can cause gastrointestinal issues, skin irritation, and neurological damage. | Monitor water quality alerts, test the quality of well water, use water filters, and take precautions when traveling. |
| Natural disasters | Individuals who live in areas that are more likely to experience flooding, fires, hurricanes, or earthquakes are at higher risk for harm. | While these events are out of the individual’s control, it is important to take action to minimize potential harm. |
| Hazardous materials | Exposure to hazardous materials such as lead, asbestos, or chemicals can cause serious health implications or death. | Be aware of safety labels on chemicals and cleaning products, reduce exposure to harmful substances, and properly dispose of any hazardous materials. |
| Political and social factors | Living in areas where there is political unrest, wars, or terrorism increases an individual’s risk. | These events are out of the control of the individual, but it is important to be prepared to minimize their risk. |
Risk for Falls
Falls are a common and serious problem for many individuals, and even more so for older adults. Falls can result in serious injuries such as broken bones, head injuries, and even death (AHRQ, 2023). Physical factors such as poor balance, weak muscles, and limited mobility can increase the risk of falls. Each year, 3 million older people are treated in emergency departments for fall injuries, and over 800,000 patients a year are hospitalized because of a head injury or hip fracture resulting from a fall (CDC, 2023a). “Prevent residents from falling” is one of the National Patient Safety Goals for nursing care centers (The Joint Commission, 2023). Many older adults who fall, even if they are not injured, become afraid of falling. This fear may cause them to limit their everyday activities. However, when a person is less active, they become weaker, which further increases their chances of falling (CDC, 2020a).
Life-Stage Context
Preventing Accidents in Older Adults—Implementing a Unique Model
The CDC (2020b) developed a program called “STEADI: Stopping Elderly Accidents, Deaths & Injuries” to help reduce the risk of older adults falling at home. This model was created in response to fall risk as well as a desire to implement a strengths-based model to assist older individuals to stay safely at home. The model consists of three screening questions to determine risk for falls:
- Do you feel unsteady when standing or walking?
- Do you have worries about falling?
- Have you fallen in the past year? If yes, how many times? Were you injured?
If the individual answers “Yes” to any of these questions, further assessment of risk factors is performed. This additional assessment supports nurses and other healthcare providers in implementing measures to support people in remaining safe in their homes.
Many conditions contribute to patient falls, including the following (CDC, 2020a):
- lower body weakness
- vitamin D deficiency
- difficulties with walking and balance
- medications, such as tranquilizers, sedatives, antihypertensives, or antidepressants
- vision problems
- foot pain or poor footwear
- environmental hazards, such as throw rugs or clutter that can cause tripping
Most falls are caused by a combination of risk factors. The more risk factors a person has, the greater are their chances of falling. Many risk factors can be changed or modified to help prevent falls.
Unfolding Case Study
Unfolding Case Study #2: Part 3
Refer back to Chapter 8 Admission, Transfer, and Discharge for Unfolding Case Study Parts 1–2 to review the patient data. A 65-year-old patient was admitted to the cardiology unit for observation after a suspected myocardial infarction. The patient went to the cardiac catheterization lab, where two coronary artery stents were successfully placed. The patient has just returned to her room after the procedure. During morning rounds, the team noted the patient appears restless and agitated. She repeatedly attempts to get out of bed without assistance, despite reminders to call the nurse before getting up.
| Past Medical History | Medical history: Hypertension, type 2 diabetes, coronary artery disease Family history: Mother deceased, father alive with severe dementia; two healthy sons in their early 40s Social history: Previous divorce, married to current husband, George, for twenty years Allergies: Latex Current medications:
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| Flow Chart | 1200: Assessment Blood pressure: 135/82 mm Hg Heart rate: 97 beats/min Respiratory rate: 20 breaths/min Temperature: 98.6°F (37°C) Oxygen saturation: 95 percent on room air Pain: 5/10 (headache) |
| Nursing Notes | 1200: Assessment Patient reports headache pain rated 5/10 on numerical scale. Oxycodone previously administered at 1030 for postprocedure pain. |
Risk for Fires
Fires are frightening and pose a significant risk for serious injuries, loss of property, and even death. The kitchen poses the highest likelihood of fire hazards within a home. These can occur from improperly using equipment, leaving cooking food unattended, having flammable materials near stoves or open fires, and not turning off appliances when they are not in use. Another common fire hazard can occur from smoking in bed, falling asleep while smoking, and improperly disposing of smoking equipment. Heating sources also pose a risk to safety, particularly items such as unattended space heaters, fireplaces, and candles. By taking steps to reduce the risk of fire and having fire safety equipment present in the home and workplace, individuals can decrease their risk.
Risk for Poisoning
Poisoning is a serious public health issue and can result in serious injury or death, particularly in small children. Household hazards such as cleaning products, laundry products, or medications can pose a poisoning risk. Additionally, consumption of contaminated food or beverages can lead to food-related poisoning, while exposure to lead or carbon monoxide in homes or workplaces can result in fatal outcomes. There are numerous steps individuals can take to ensure their own safety and prevent illness, injury, or death from poisoning. One of the first steps is education. Patients must be taught which products in the home may be toxic if they are ingested, such as household cleaning products or laundry pods. These products contain warning labels, and any products that are considered toxic or harmful should be stored in a safe place away from children and pets. Keep poison control numbers nearby in case of emergency, and recognize when to get assistance.
Risk for Suffocation
Suffocation occurs when an object impairs an individual’s airway. Infants and young children are most susceptible to the risks of suffocation. Choking hazards, like small toys or food, pose a risk of becoming lodged in a child’s airway. Additionally, suffocation may occur if an infant or young child’s airway becomes obstructed during sleep, commonly attributed to bedding. Nurses can educate parents on safe sleeping practices to reduce the risk of suffocation for infants. This includes placing the infant on their back to sleep, using firm mattresses, avoiding pillows or additional bedding, refraining from co-sleeping, ensuring the infant is at a comfortable temperature, and keeping soft or loose objects away from the sleeping area (Moon, 2022).
Other risks for suffocation for children include scarves or ties from clothing, such as hoodies, becoming caught and playing with items that might become caught around their throat. Ensure children do not have coats or mittens with strings that might get caught while playing on outdoor equipment causing suffocation and ensure individuals do not perform risky activities with items around their neck or mouth (Nemours KidsHealth, 2023).
Adolescents and adults also experience suffocation risks, most often from inhalation or aspiration of foreign substances or food and inflicted injury from strangulation or hanging (Sasso et al., 2018). Educate adolescents not to engage in dangerous or life-threatening activities, such as social media trends that may be dangerous and are not proven safe. For adults, ask if they indulge in air deprivation or suffocation games. Discuss educational resources to help educate patients on suffocation prevention while engaging in sexual activity. These conversations might be awkward and embarrassing, but they are necessary to ensure the safety of patients.
Risk for Exposure to Substances
Substance use has a negative impact on health and can also increase the individual risk for harm or illness. Substances to which individuals may be exposed include alcohol and drugs (both legal and illegal). Unfortunately, some patients become dependent on drugs that may have been prescribed to manage pain, such as opioids, leading to substance use disorders. As substance use disorder evolves, patients seek out more ways to obtain drugs to manage the symptoms of withdrawal. The effects of substance use are discussed in greater detail in 9.2 Safety: Violence.
Risk for Impaired Thermoregulation
The ability of the body to maintain its internal temperature within a narrow range is called thermoregulation. Impaired thermoregulation refers to a condition where the body’s ability to regulate its internal temperature is compromised. When thermoregulation is impaired, the body may struggle to maintain its temperature within the normal range. This can lead to either hypothermia or hyperthermia, both of which can be dangerous and potentially life-threatening.
A condition that occurs when the body loses heat faster than it can produce it is called hypothermia. This can result in a dangerously low body temperature and can be life threatening. Individuals should do the following to reduce the risk of hypothermia:
- Dress appropriately for the weather to reduce the risk. In severe cold, individuals should avoid being outdoors if possible.
- Stay active to generate body heat and reduce the risk of hypothermia.
- Avoid alcohol and drugs, as they can impair judgment and increase the risk of hypothermia. For example, a person who is impaired by either alcohol or drugs may choose to go outside when the weather is extremely cold and may not recognize how cold it is, perhaps losing consciousness or falling asleep in the cold, leading to hypothermia.
A condition that occurs when the body produces or retains too much heat is hyperthermia. This can result in a dangerously high temperature and can be life threatening. To reduce the risk of hyperthermia, individuals should do the following:
- Stay hydrated to help regulate body temperature.
- Avoid strenuous activity in hot weather to reduce risk, and if possible, stay in air-conditioned areas during extreme heat.
- Wear appropriate clothing, such as lightweight, light-colored clothing in hot weather.
Workplace Safety Concerns
The workplace can present a variety of safety concerns, ranging from physical hazards such as slips, trips, and falls, to chemical exposure to ergonomic concerns and stress. The repetitive nature of work can lead to workplace injuries. The design and arrangement of workspaces, tools, equipment, and tasks to optimize comfort, efficiency, and safety for employees is called ergonomics. Ergonomics involves assessing how people interact with their work environment and identifying potential hazards or discomforts, such as uncomfortable chairs, poorly designed workstations, repetitive motions, heavy lifting, and inadequate lighting that can result in musculoskeletal injuries or other health problems. To implement ergonomic principles, workplaces should provide training and education to employees, offer support and resources for stress management, and create a positive organizational culture that prioritizes employee well-being.
Employees should stay vigilant about workplace safety hazards and understand their employers’ legal obligations to ensure a secure work environment. Reporting safety issues to the relevant authorities, engaging in mandatory safety training, and adhering to prescribed safety procedures are crucial. Additionally, workers should be mindful of workplace stressors and seek methods to alleviate physical, mental, and emotional stress.
Never Events
Adverse events that are clearly identifiable, measurable, serious (resulting in death or significant disability), and preventable are called never events. In 2007, the Centers for Medicare and Medicaid Services (CMS) discontinued payment for costs associated with never events, and this policy has been adopted by most private insurance companies (AHRQ, 2019). Never events are publicly reported, with the goal of increasing accountability by healthcare agencies and improving the quality of patient care. The current list of never events includes seven categories of events:
- surgical or procedural event, such as surgery performed on the wrong body part
- product or device, such as injury or death from a contaminated drug or device
- patient protection, such as patient suicide in a healthcare setting
- care management, such as death or injury from a medication error
- environmental, such as death or injury as the result of using restraints
- radiological, such as a metallic object in an MRI area
- criminal, such as death or injury of a patient or staff member resulting from physical assault on the grounds of a healthcare setting
Table 9.4 demonstrates the various ways in which patients can be impacted by never events. To reduce the chance and impact of never events, healthcare providers should focus on preventing these events using evidence-based practices, robust quality improvement processes, and patient engagement and empowerment. Patients can take steps to avoid experiencing never events by becoming informed and engaged in their own health care by asking questions and speaking up if they have concerns.
| Action | Potential Outcome |
|---|---|
| Physical | Pain, infection, or another injury that might result in long-term complications and impact the quality of life |
| Psychological | Anxiety, depression, and post-traumatic stress disorder may occur and be long lasting |
| Increased healthcare costs | Longer hospital stays, additional treatments, and rehabilitation services can cost the healthcare system billions of dollars |
| Loss of trust | Loss of trust between the patient and provider and the healthcare system in general |
Clinical Safety and Procedures (QSEN)
QSEN Competency: Safety
Definition: Minimizes risk of harm to patients and providers through both system effectiveness and individual performance.
Knowledge: The nurse will delineate general categories of errors and hazards in care.
Skill: Describe factors that create a culture of safety (such as open communication strategies and organizational error reporting systems).
Attitude: Seeking to value one’s role in preventing error. For example, one type of “never event” is a wrong-site surgery. This refers to a surgical procedure performed on the wrong part of the body, such as the wrong limb or organ. To prevent wrong-site surgery, the Quality and Safety Education for Nurses (QSEN) project emphasizes the importance of implementing a preoperative verification process. This involves verifying the correct patient, correct site, and correct procedure before the surgery takes place. This process can involve multiple healthcare team members, including the surgeon, anesthesiologist, and nursing staff. By emphasizing the importance of a preoperative verification process and the use of standardized protocols, QSEN helps to ensure that healthcare teams are equipped with the tools and knowledge to prevent errors and provide safe care.
Near Events or Misses
A near event is a warning signal of a potential hazard or incident that may cause harm to patients. Near events can have significant negative impacts; however, they can also provide an opportunity for learning and improvement. A near miss is an error that has the potential to cause harm but is identified before it happens. Near misses, such as those involving medications, allow nurses to make changes to practice and policy. Near misses are rarely the result of poor motivation or incompetence of the healthcare professional but rather are often caused by key contributing factors such as poor communication, less-than-optimal teamwork, memory overload, reliance on memory for complex procedures, and lack of standardization of policies and procedures.
Clinical Judgment Measurement Model
Recognize Cues: Noticing Patterns and Responding
The nurse is responsible for recognizing cues and responding to cues that are out of the norm or not expected. In the instance of a near event involving the administration of a mislabeled medication, this would involve recognizing an error on the medication bottle and intervening before the medication is given. Upon noticing the error, the nurse should immediately stop medication administration and return to the medication cart. They should seek to understand reasons for why a near miss occurred. The nurse should speak with a supervisor to identify the issue and seek resolution to prevent such an error from occurring again.
Sentinel Events
A sentinel event is like a near event but is not necessarily preventable. A sentinel event is defined as an unexpected occurrence involving death or serious physiological or psychological injury, or the risk thereof. For example, injury or death from a properly prescribed and administered medication is a sentinel event. The Joint Commission mandates reporting of sentinel events and the performance of a root cause analysis by the healthcare agency. A root cause analysis is a structured method used to analyze serious adverse events to identify underlying problems that increase the likelihood of errors, while avoiding the trap of focusing on mistakes by individuals. A multidisciplinary team analyzes the sequence of events leading up to the error with the goal of identifying how and why the event occurred. The goal is to prevent future harm by eliminating hidden problems within a healthcare system that contribute to adverse events.
Root cause analysis uses human factors science as part of the investigation. A human factors approach focuses on the interrelationships among humans, the tools and equipment they use in the workplace, and the environment in which they work. Safety in health care is ultimately dependent on humans—the doctors, nurses, and healthcare professionals—providing the care. For example, when a medication error occurs, a root cause analysis goes beyond focusing on the mistake by the nurse and looks at other system factors that contributed to the error, such as similar-looking drug labels, placement of similar-looking medications next to each other in a medication dispensing machine, or vague instructions in a provider order.
Culture of Safety
A culture of safety is a workplace culture that prioritizes the well-being and safety of employees, patients, and the public. Culture can have many definitions but generally refers to a way of being or acting. A culture of safety is characterized by open communication, collaboration, and continuous improvement, with a focus on reducing errors, adverse events, and harm. A culture of safety significantly impacts individual safety, as it sets the tone for safety practices, behaviors, and attitudes in the workplace. One example of a culture of safety initiative is the implementation of crew resource management (CRM) training in healthcare settings. In healthcare, CRM is a human factors approach that focuses on improving communication, teamwork, and situational awareness among healthcare providers. Studies have shown that CRM training can improve patient safety outcomes, reduce adverse events, and improve overall healthcare team performance (Weaver et al., 2011).
Just Culture
A just culture can be defined as a culture where people feel safe raising questions and concerns and reporting safety events in an environment that emphasizes a nonpunitive response to errors and near misses. Clear lines are drawn between human error, at-risk behavior, and reckless behavior:
- Simple human error occurs when an individual inadvertently does something other than what should have been done. Most medical errors are the result of human error due to poor processes, programs, education, environmental issues, or situations. These errors are managed by correcting the cause, looking at the process, and fixing the deviation.
- At-risk behavior occurs when a behavioral choice is made that increases risk where the risk is not recognized or is mistakenly believed to be justified. For example, a nurse scans a patient’s medication with a barcode scanner prior to administration, but an error message appears on the scanner. The nurse mistakenly interprets the error to be a technology problem and proceeds to administer the medication resulting in the wrong dosage of a medication being administered to the patient, instead of stopping the process and further investigating the error message. In this case, ignoring the error message on the scanner is considered at-risk behavior because the behavioral choice was considered justified by the nurse at the time.
- Reckless behavior occurs when an action is taken without regard for a substantial and unjustifiable risk. For example, a nurse arrives at work intoxicated and administers the wrong medication to the wrong patient. This error is due to reckless behavior because the decision to arrive intoxicated was made with conscious disregard for substantial risk.
Creating a just culture in which employees are not afraid to report errors is a highly successful way to enhance patient safety, increase staff and patient satisfaction, and improve outcomes. Success is achieved through good communication, effective management of resources, and an openness to changing processes to ensure the safety of patients and employees.
National Patient Safety Goals
Every year, to improve patient safety, The Joint Commission publishes National Patient Safety Goals that include goals and recommendations tailored to seven different types of healthcare agencies based on patient safety data from experts and stakeholders. The seven healthcare areas include ambulatory healthcare settings, behavioral healthcare settings, critical access hospitals, home care, hospital settings, laboratories, nursing care centers, and office-based surgery settings. These goals are updated annually based on safety data and include evidence-based interventions. The National Patient Safety Goals for nursing care settings (otherwise known as long-term care centers) are described in Figure 9.5.
Unfolding Case Study
Unfolding Case Study #2: Part 4
Refer back to Unfolding Case Study: Unfolding Case Study #2: Part 3 for a review of the patient data.
| Nursing Notes | 1400: Assessment During hourly rounding, patient was found lying on the floor. Patient states, “I needed to go to the bathroom, but you were taking too long to come help me!” Upon further assessment, the bed alarm was turned off, and there was no evidence of the patient’s call light being pushed for assistance. Patient was helped back to bed by three nursing staff and fall reported to charge nurse. |
Social Determinants of Health
The social determinants of health (SDOH) are the economic, social, and environmental factors that influence an individual’s health and well-being. The term health disparity describes the differences in health outcomes that result from SDOH. The SDOH are conditions in the environment where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes. Resources that enhance quality of life can have a significant influence on population health outcomes. Examples of resources include safe and affordable housing, access to education, public safety, availability of healthy foods, local emergency/health services, and environments free of life-threatening toxins (Healthy People 2030, n.d.).
At-risk populations experience increased prevalence and burden of diseases, as well as problems accessing quality health care because of SDOH. Health disparities negatively impact groups of people based on their ethnicity, gender, age, mental health, disability, sexual orientation, gender identity, socioeconomic status, geographic location, or other characteristics historically linked to discrimination or exclusion (Healthy People 2030, n.d.). A related term is healthcare disparity which refers to differences in access to health care and insurance coverage. Health disparities and healthcare disparities can lead to decreased quality of life, increased personal costs, and lower life expectancy. More broadly, these disparities also translate to greater societal costs, such as the financial burden of uncontrolled chronic illnesses.
Limited Access to Food and Water
Limited access to food and clean water can have a significant impact on individual safety and well-being. Addressing this issue through policies and programs that ensure access to safe and nutritious food and clean water is essential for improving health outcomes and reducing health disparities. Limited access to food and water can lead to health issues, such as malnutrition, dehydration, foodborne illness, and waterborne illness, and impact mental and physical health in general. Some communities are further impacted by “food deserts,” or areas where it is impossible for those who are poor to purchase affordable, quality, healthy food due to location and lack of adequate public transportation.
Substandard Housing
Adequate and affordable housing is a critical social determinant of health. Poor housing conditions, including overcrowding, lack of heat and running water, and exposure to toxic substances, can lead to a range of health problems, including respiratory diseases, injuries, and mental health conditions. A well-constructed questionnaire can help nurses eliminate bias while obtaining necessary information.
Limited Support System
A limited support system can have a significant impact on individual safety and well-being. Support systems may consist of family, friends, or neighbors who maintain contact with those living alone to ensure their safety and well-being. A limited support system can lead to individuals having a lack of assistance with daily activities, increased isolation and loneliness, difficulty navigating health systems, limited access to resources, and increased risk of neglect and abuse. Addressing this issue through policies and programs that support social connectedness and provide access to resources and services is essential for improving health outcomes and reducing health disparities.