Despite constant awareness on patient safety, patients are unfortunately still suffering unnecessary consequential harm. As healthcare providers we need to ensure that the services we offer to our patients are safe, effective, caring, responsive, and well led. We need to communicate efficiently and lead by example in all areas of patient care.
Patient Safety is a health care discipline that emerged with the evolving complexity in health care systems and the resulting rise of patient harm in health care facilities. It aims to prevent and reduce risks, errors and harm that occur to patients during provision of health care. A cornerstone of the discipline is continuous improvement based on learning from errors and adverse events…
Patient safety is fundamental to delivering quality essential health services…
To ensure successful implementation of patient safety strategies; clear policies, leadership capacity, data to drive safety improvements, skilled health care professionals and effective involvement of patients in their care, are all needed.
WHO, 2019.
Patient Safety Issues
Healthcare-Associated Infections
Each year, about 1 in 25 U.S. hospital patients is diagnosed with at least one infection related to hospital care alone; additional infections occur in other healthcare settings.
CDC, 2017.
Hand hygiene, antimicrobial stewardship, and other protocols, seem to be directly related to the rate and prevalence of healthcare-associated infections, including surgical site infections.
Antibiotic Resistance and Stewardship
Each year in the United States, at least 2.8 million people get an antibiotic-resistant infection, and at least 35,000 people die.
CDC, 2019.
We seem to be headed towards a situation in which antibiotics are rendered useless – a situation which we may be encountering sooner than we expect. This is due to current antibiotic prescription practices, lack of new antibiotic development, and the speed with which pathogens are developing resistance to currently available antibiotics.
Hand Hygiene
Whilst hand hygiene has been proven as the first line of defence against infection, it is still one of the least used tactics, as clearly shown in compliance rates.
Personal Protective Equipment
Lately, in 2020, due to the outbreak of COVID-19, nursing unions worldwide have pushed towards better protective gear and safety precautions, along with increased education and training about treating patients in a safe, effective manner.
Workforce Safety
Adequate nurse-to-patient staffing ratios protect our patients’ right to nursing care and safety. Problem is, in many clinical areas, there is no adequate nurse-to-patient staffing ratio, and this is leading to physical and psychological issues amongst healthcare employees. Ensuring safety of the workforce and within the workplace itself is crucial in ensuring patient safety.
Medication Errors
Medication errors are among the most common medical errors, harming at least 1.5 million people every year.
Institute of Medicine of the National Academies, 2007.
Medication errors to not just jeopardise patient safety; they also lead to unnecessary increased costs. Most medication errors can be avoided through better communication between the patient and the healthcare provider, or between the pharmacist and the patient, as well as adequately following medication-related protocols.
Transition of Care
Transitions of care happen with every physical transfer of patient and change of physician or nurse handover. For optimum transition of care, communication is critical. Information needs to be provided accurately with each transition in a way so that patient care can start right away without the need to read through documentation prior to physically assessing and communicating with the patient.
Patient Engagement
Patients need to be involved in their treatment plans and processes. As healthcare professionals we need to empower our patients so that they become allies in their own care, serving as another layer of defence against safety issues.
For this to happen, one needs to consider the patient’s health literacy so the information given by the healthcare professional is both understood and followed as required.
Pressure Injuries
Pressure injuries can be avoided through multiple efforts. Adequate nursing assessments need to be carried out as per recommendations, especially during bathing time. Thorough patient assessments can help determine risks for pressure injuries, and in such case, ulcer relief equipment needs to be available and sought to avoid unnecessary issues.
Through education on the prevention of pressure injuries along with providing patient-centered care, unnecessary complications can be avoided.
Patient Falls
More than one-third of in-hospital falls result in injury, including serious injuries such as fractures and head trauma.
Agency for Healthcare Research & Quality, 2019.
Through patient-centered care, the needs of each patient can be identified, noted, and met. Optimum communication in transition of care ensures that patient falls are reduced to a minimum.
Information Technology issues
Whilst health IT aims to quicken processes, aggregate and analyse data efficiently and improve outcomes, actual implementation has shown that the scope of technology’s reach has been much shorter than anticipated. This has led to a situation conducive to human error, jeopardising patient safety in the process.
To avoid such situation, technology should be enhanced so it can be used to improve communication within and between multidisciplinary teams, promote timely care, and provide data in a way which enhances monitoring and evaluation of patient care.
Use of Restraints
Use of restraints may seem to be unnecessary measures which take a patient’s personal freedom away. However, in certain situations, restraining a patient is the only way in which the patient’s safety can be ensured.
Use of restraints include:
- Physical Restraints: interventions or devices which prevent the patient from moving freely, restricting normal access to his/her own body
- Chemical Restraints: use of drugs to restrict patient movement or behaviour (drug or dosage in such case isn’t an approved standard of treatment for the patient’s condition).
NOTE: The following are NOT considered as restraints, but as safety interventions: orthopaedic supportive devices, age-appropriate protective equipment eg. strollers and helmets, keeping bed side-rails up as a precautionary measure in case of a seizure, and devices used to temporarily immobilise a patient for a diagnostic procedure.
Ethical Issues
- Obligations & Duties – as healthcare professionals, identifying our moral obligations to others can help us determine our course of action in any given situation
- Avoiding Harm – as healthcare professionals, our main aim and basis for good practice should always be that of avoiding harm to our patients
- Assessing Consequences of Action – prior to use of restraints we should always assess the balance between benefits vs harm
- Autonomy & Rights – we need to respect the individual’s rights to make their own decisions (if having the mental capacity to do so) and respect for the rights of others
Legal Issues
- Does the patient lack capacity in relation to the matter in question?
- Is it truly necessary to restrain the patient in order to prevent harm to the patient?
- Have you considered the likelihood of the patient being harmed and the seriousness of that harm?
Risks related to Use of Restraints
- A supine restrained position may increase the risk of aspiration
- A prone restrained position may increase the risk of suffocation
- An improperly secured above-the-neck vest may increase the risk of strangulation (if patient slips through the side rails)
- Restraints may cause psychological trauma or resurface traumatic memories
- Restraints can cause serious injuries and even death
Reducing the Risks…
- ensure that a physical restraint is applied safely and appropriately
- frequently monitor patients with any type of restraint
- provide reassurance, support, and frequent contact to relieve a restrained patient’s fear and anxiety
- monitor vital signs to determine how the patient is responding to the restraint
- nurses need to receive hands-on training on the use and appropriate application of all types of restraints prior to being required to apply them, which training should be reinforced periodically
NOTE: Use of restraints should not be made part of a routine protocol, but an exceptional event!
The Role of the Nurse in Use of Restraints
- Nurses must weigh the risks of using a restraint – restraints may cause physical or psychological trauma. Which is the best option? Is there a possibility of addressing the issue at hand without restraints and in a different way eg. through communication leading to reduction of anxiety?
- Restraints should be used as a last resort. Nurses should explore alternatives such as having staff or family members to sit with the patient, using distractions or de-escalation strategies, and reassurance.
- If use of restraints is necessary, a provider order must be obtained. However, this will not determine future need for restraints. Nurses should update and revise the patient’s care plan with the aim of reducing restraining measures and episodes.
Elevated Supervision ~ Constant Watch
ELEVATED SUPERVISION IN PSYCHIATRIC NURSING
In psychiatric nursing, constant watch by a professional staff member is recommended when the patient is at risk of harming self or others, as well as to observe the patient’s behaviour.
ELEVATED SUPERVISION IN NURSING (SPECIALLING NURSING)
Nursing care may be required on a one-to-one basis if the patient has so many needs that nursing assistance is required at all times. One-to-one nursing a.k.a. specialling nursing in such cases requires that the patient is kept within sight at all times of the day and night. This helps in reducing the risk and incidence of patient harm.
Whilst specialling nursing can feel intrusive and restrictive, it can be a therapeutic intervention through patient-centered care.
To ensure patient safety as well as your own…
- ensure a good handover from the nurse in charge, including the reason why 1:1 nursing has been implemented
- inform yourself about your patient’s recent days at the hospital through patient notes and documentation
- participate in discussions with the patient’s family, carers, and other healthcare staff
- liaise with the multi-disciplinary team and ensure the patient attends all due appointments and required tasks
- ensure clarification about break time and who is to provide cover whilst on break
- document in detail, including patient speech content, behaviour, risks, and attitude to being under constant watch
Specialling Nursing Patient Care
- communicate with the patient and provide reassurance
- assist with personal hygiene and other personal needs such as wearing of hearing aids, glasses, dentures, as well as toileting
- promote mobilisation where possible so as to maintain daytime activity and stimulation, leading to better nights where the patient can sleep better
- liaise with other personnel where need be so as to provide the patient with any cultural and spiritual needs
- communicate with carers about the patient’s needs and assist them with any concerns
- always keep in mind the patient’s preferences to activities of daily living; What is their normal routine like? Does the patient have any preferences with regards to bathing and dressing up? What are the patient’s food preferences? How is the patient’s usual bowel routine? Does the patient ask for painkillers? How is the patient’s mobility? Any activities of interest that the patient can continue to practice whilst hospitalised? In case of inappropriate or difficult behaviour, how is this usually managed?
constant watch Hospital Policies
- most clinical areas have their own SOPs – Standard Operational Procedures; always ask if they exist, and if they do, read them, understand them, and if unclear, ask for clarifications
- challenge related malpractice
- provide daily patient review on the need for constant watch and the different levels of elevated supervision as should be explained in the SOP; get the GP or consultant to sign and review patient on a daily basis
References
Agency for Healthcare Research & Quality (2019). Patient Safety 101. Retrieved from https://psnet.ahrq.gov/primer/falls on 12th June 2022.
Centers for Disease Control and Prevention (2019). Antibiotic Resistance. Accessed from https://www.cdc.gov/winnablebattles/report/HAIs.html on 11th June 2022.
Centers for Disease Control and Prevention (2017). Healthcare-Associated Infections (HAIs). Accessed from https://www.cdc.gov/winnablebattles/report/HAIs.html on 11th June 2022.
Institute of Medicine of the National Academies (2007). Preventing Medication Errors. DOI: https://doi.org/10.17226/11623
World Health Organization (2019). Patient Safety. Assessed from https://www.who.int/news-room/fact-sheets/detail/patient-safety on 11th June 2022.
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