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Concept – Definition / Scope:
Safety is “freedom from accidental injuries; ensuring patient safety involves the establishment
of operational systems and processes that minimize the likelihood of errors and maximizes the
likelihood of intercepting them when they occur.” IOM—To Err Is Human, 2000
Learning Outcomes
Define and describe safety.
 Patient safety, one of the quality domains, is defined as “the pursuit of the reduction
and mitigation of unsafe acts within the health care system, as well as the use of best
practices shown to lead to optimal patient outcomes”
Describe common physiological changes associated with aging.
 Integument
o Loss of skin elasticity wrinkles, sagging, tears easily
o Decreased adipose tissue
o Decreased efficiency of sweat glands
 Respiratory
o Decreased cough reflex, decreased removal of mucus & irritants from airways
o Inefficient gas exchange
o Increased chest wall rigidity
o Fewer alveoli, increased airway resistance
o Increase risk of respiratory infections
 Cardiac
o Thickening of blood vessels
o Increased peripheral vascular resistance
o Loss of vessel elasticity
o Lower cardiac output
o Decreased baroreceptor sensitivity
o Increased systolic B/P
o Decrease peripheral circulation
 GI
o Periodontal disease
o Loss of teeth
o Decreased saliva, gastric secretions, pancreatic enzymes
o Changes in smooth muscle (decreasing peristalsis & motility of the GI tract)
 Musculoskeletal
o Decreased muscle mass & strength
o Decalcification of bones & degenerative joint changes
o Dehydration of intervertebral disks (decreased height)
 Neuro
o Degeneration of nerve cells
o Decrease in neurotransmitters
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o Decreased rate of impulse conduction
Sensory
o Presbyopia, altered perception of colors, increased sensitivity to glare
o Yellowing of lens of eye & difficulty adjusting to changing light, smaller pupils
o Loss of hearing (high frequency tones, thickening of tympanic membrane
o Diminished taste
o Diminished smell
o Decreased ability to respond to water load deficits
o Decreased awareness of body positioning in space
Reproductive
o Women – Decreased estrogen production, atrophy of vagina, breasts, & uterus
o Men – Diminished sperm, smaller testes, Less firm & slower erections
GU
o Weakened bladder muscles, decreased bladder capacity, decreased renal mass &
number of nephrons (decreased renal function)
Endocrine
o Diminished ability to respond to stress due to decreased hormones
o Increased level of anti-inflammatory hormones
Physical Appearance
o Hair turns grey & thins
o Wrinkles
o Decreased height
o More hair in nose and ears
o Facial hair in women
o Deepening hallows, underarms and between ribs
o Diminished muscle mass
Personality
o Usually no drastic changes (if kind & gentle when older probably was always that
way)
Memory
o Retrieval of long term memory may be slower (esp infrequently used info)
o Working memory may be reduced (cannot do too many things at once)
o May be somewhat forgetful
Intelligence
o Basic intelligence do not change
o Do not become less intelligent with age
o Fluid intelligence (new info) is thought to decline in later life
Learning
o Learning ability does not seriously alter
o May be less ready to learn
o Factors that may interfere with learning – attention span, motivation, perceptual
deficits, illness
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List the impact of age-related changes on the function and safety of the environment.
 Physiological changes
o Changes in vision, hearing, mobility, reflexes, circulation, and the ability to make
quick judgements predispose older persons to falls.
o When a patient is hospitalized, confusion, multiple medical problems,
medications, immobility, urinary urgency, age-related sensory changes, postural
instability, and an unfamiliar environment further contribute to the risk of falls.
o Certain disease states common to older persons, such as arthritis and
cerebrovascular accidents, also increase the chances of injury.
o Unintentional falls were the most common cause of injury in adults aged 65
years and older, with 70% of injuries in this age group caused by falls.
o Patients most often fall while transferring from beds, chairs, and toilets; while
getting into or out of a bathtub; by tripping over carpet edges or doorway
thresholds; by slipping on wet surfaces; and while descending stairs. Icy
walkways and obstacles in the yard are also common causes of outdoor falls in
older persons.
 Age related factors
o History of falls
o Females over the age of 75 years
o Impaired vision
o Gait disturbance
o Postural hypotension
 Health conditions or functional impairments related to falls
o Physical disability
o Incontinence, nocturia
o Delirium, dementia
o Mood disturbances
o Dizziness, Weakness, fatigue
o Ataxia
o Paralysis
o Edema
o Use of walking device (cane, walker, etc)
o Use of restraints
o Presence of IV, catheter
o Unstable cardiac conditions (TIA, CVA)
o Neurologic disease (Parkinson's)
o Diabetes (Peripheral vascular disease, foot problems)
 Medications
o Polypharmacy
o Antidepressants, Antipsychotics
o Antihypertensive, Diuretics
o Sedatives, Tranquilizers
 Environmental factors
o Newly admitted to hospital / nursing home (unfamiliar surroundings)
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Highly polished floors
Inadequate lightening
Absence of rails, grab bars (e.g., in Bathrooms)
Poor environmental design
Clutter, equipment
Discuss safety and restraints
 A restraint is a physical, chemical, or environmental means of controlling an individual's
behaviour or actions.
 It is imperative that nurses try alternative measures as the application of a restraint
should always be a measure of last resort.
 A restraint-use algorithm provides evidence-informed guidelines for determining
whether a restraint is appropriate and what interventions might be used.
 Patients who are at risk for injury to self or others may need physical restraints
temporarily. Physical restraints do not prevent falls and may increase the severity of an
injury from a fall
 Whenever patients are physically restrained, there is a natural tendency for them to try
to remove the restraint, and this can lead to injury.
o Serious complications include
o Pressure injuries, constipation, pneumonia, urinary+ fecal incontinence, and
urinary retention.
o Contractures, nerve damage, and circulatory impairment
o Patients can experience humiliation, fear, anger, and a loss of self-esteem.
 Alternatives to Restraints
o Orient patients and families with the care environment; explain all procedures
and treatments.
o Provide companionship and supervision; use trained sitters or adjust staffing.
o Diversionary activities, such as music or holding something; support from family.
o Confused or disoriented patients close to nurse station for frequent observations
o Use calm, simple statements and physical cues as needed.
o De-escalation, time-outs, etc when managing aggressive behaviours.
o Provide visual and auditory stimuli (e.g., family pictures, a clock, or a radio).
o Remove cues that promote leaving (e.g., sight of elevators, stairs)
o Promote relaxation techniques and normal sleep patterns.
o Institute exercise as allowed by patients' conditions; consult a physiotherapist
o Attend to the patient's toileting, food, and fluid needs.
o Camouflage intravenous lines with clothing, a stockinette, or a Kling dressing.
o Evaluate all medications the patients are receiving and ensure effective pain
management.
o Reassess physical status of patients, and review lab findings.
 Nurses must know the agency's policy and procedures for the appropriate use and
monitoring of physical restraints.
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The use of a restraint must be clinically justified and be a part of the patient's prescribed
medical treatment and care plan. A physician's order may be required, depending on
agency policy (in some settings, nurses may order).
Assessment of patients who are restrained must be ongoing. Proper documentation,
including the behaviours that necessitated the application of restraints, the procedure
used in restraining, the condition of the body part restrained (e.g., circulation to the
patient's hand), and the evaluation of the patient response, is essential.
Restraints should be removed periodically, and the patient should be assessed to
determine if the restraints continue to be needed.
An Ambularm is a device worn on the leg that signals when the leg is in a dependent
position, such as over the side rail or on the floor.
The Bed-Check bed exit alarm system uses a weight-sensitive sensor mat that can be
placed on the patient's mattress or chair. This device sounds an audible alarm at the
bedside when pressure is released off the sensor mat. Such devices are useful for
patients who tend to climb out of bed unassisted but are in danger of falling.
Other alarms can be placed on doors to alert staff or family members when a confused
patient, prone to wandering, opens a door.
Chemical restraint is defined as “any form of psychoactive medication used, not to treat
illness, but to intentionally inhibit a particular behaviour or movement”.
o For example, it may be necessary to sedate a patient who is consistently pulling
out a nasogastric tube.
o As with any other restraint, chemical restraints should be implemented only
after non-restraining measures (e.g., distraction, use of a sitter) have proven
ineffective and with the informed consent of the patient or their substitute
decision maker.
o Proper adherence to medication administration guidelines is vital to the safe use
of chemical restraints, and the patient's response to and need for these
medications must be assessed on a regular basis.
Discuss safety and falls
 Falls account for up to 90% of all reported incidents in hospitals.
 In addition to age, a history of previous falls, gait disturbance, balance and mobility
problems, postural hypotension, sensory impairment, urinary and bladder dysfunction,
use of medications, and certain medical diagnostic categories (e.g., cancer and
cardiovascular, neurological, and cerebrovascular diseases) increase the risk of falling.
o Common factor for a fall is a patient's attempt to get out of bed to use the toilet.
 Hip fractures are among the most serious fall-related injuries. The rate of hip fracture in
Canadian older persons during admission to hospital was close to 1 in 1 000.
o A hip fracture may have a long recovery or may not be able to return to their
previous level of functioning, even losing their ability to live independently.
 Falls that result in injuries can extend a patient's length of stay in the health care
environment, placing the patient at a greater risk for other complications.
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Nurses can implement multifaceted interventions to reduce the risk of falls, including
assessment and communication about patient risks, staff assignments in close
proximity, signage, improved patient hand-offs, nurse toilet and comfort safety rounds,
and involving the patient and family
Identify safety in the nursing and health care practice.
 The Canadian Patient Safety Institute's Safety Competencies Framework includes the
following key concepts for nurses and other health care providers:
1. contribute to a culture of patient safety
2. works in teams for patient safety
3. communicate effectively for patient safety
4. manage safety risks
5. optimize human and environmental factors
6. recognize, respond to, and disclose adverse events
 Providing health care in a safe manner and in a safe community environment is essential
for a patient's survival and well-being.
 By incorporating critical thinking skills when following the nursing process, nurses
assume responsibility for assessing the patient and the environment for safety hazards
as well as for planning and intervening appropriately to maintain a safe environment.
 By paying attention to patient safety, nurses are functioning not only as providers of
safe care but also as an active participant in health promotion. Equally important is that
nurses must ensure their own safety as they provide patient care.
 To improve patient safety, many organizations focus on developing and monitoring key
health care safety metrics as well as providing information to health care organizations
and to the public. Health care organizations foster a patient-centred safety culture by:
o Continually focusing on performance-improvement programs.
o Acting on risk-management findings and safety reports.
o Providing current reliable technology.
o Integrating evidence-informed practice into procedures.
o Designing a safe work environment and atmosphere; and
o Providing continuing education and access to appropriate resources for staff
Readings & Resources
Giddens:
• Safety – Chapter 47
Lewis (Medical-Surgical Nursing in Canada)
• Older Adults - Chapter 7
Perry & Potter (Fundamentals):
• Older Persons – Chapter 24
• Quality and Patient Safety – Chapter 37
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