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St. Joseph’s Healthcare System
Paterson, New Jersey
Center for Education and Development
Patient Safety Class for the PCAs: Content
Safety is a basic need. Everyone wants to be safe when driving a car, taking a walk or receiving health
care. People need to be safe from accidents and dangers. Health care facilities such as hospitals are
thought to be free of dangers and hazards. This is not true and this is the reason why we are having this
classes. As direct care givers, all nurses, nurse’s aides, patient care associates and technicians has the
responsibility to provide a safe environment and assure safe delivery of patient care to our clients. Safety
measures are put in place to promote safety at SJHS.
You all care for many patients while on duty. Patients must be protected from infections, falls,
complications from the use of restraints, complications from immobility (being bed-ridden), and
equipment accidents. The right patient must also be given the right care or procedure. A person’s life
and health can be threatened if the wrong care is given.
Please tell the group that at the end of the class as PCAs they must feel empowered to make sure they
can correct their co-workers, peers and even physicians who do not practice patient safety. (done in a
courteous and respectful manner.) As PCAs they can make a difference in the nursing care of their
patients.
I.
Meaning of safety:
A. Freedom from danger, risks or injury.
B. An attitude or way of acting toward hazardous or unsafe conditions that will protect both
the health care provider and the patient
II.
Causes of injuries or accidents in the health care setting:
A. Physical limitations – lack of ability to avoid or prevent an accident
B. Poor judgment – not recognizing the danger.
C. Lack of training (employees): This is the reason why you are here. To receive appropriate
and updated information in promoting patient safety. Always ASK if you are not sure.
D. Hazardous environment: clutter, wet floors, spills on the floor, defective ambulation
devices, bed brakes, defective equipment.
E. Not knowing the patient, misidentification of the patient or not knowing the patient’s
abilities and limitations.
III.
High risk areas for mistakes in the health care environment.
A. Skipping important rules. Take your time. Do not skip important rules like patient
identification. We will go over this process.
B. Communication: Very important in the delivery of patient care. How will you be able to
take care of a patient if you do not know anything about him/her.
C. Falls: Falls kill and injure many patients each year.
D. Safe use of restraints: Be sure you are competent and able to apply restraints. If you need
help or more training, report this to the nurse. If not applied correctly or the patient is not
observed or taken cared of properly, it may cause serious complications, even death.
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E. Broken and faulty medical equipment. Do not use any patient care equipment that is
broken or not working correctly. Do not use any equipment unless you are sure how to
use it correctly.
F. Infection Control: What is the best way to prevent the spread of infection? This will be
reviewed as well.
“Now that we know the causes of injuries or accidents in the health care setting and we know
the high risk areas for mistakes let us discuss strategies to prevent these mistakes, and
promote patient safety.”
IV.
Patient Care Safety:
“How many of you have heard about the National Patient Safety goals? Can you tell me one
that affects your role as a PCA, or Nurse’s Aide or technician?“ Reward the person who
gives a correct or close to a correct answer.
A. The National Patient Safety Goals specific to the PCA job roles are:
1. Patient identification: reduce risk of misidentification. (very, very important). How
do you think it could affect patient care? Yes, it could cause wrong treatment,
wrong medication, wrong intervention and cause harm.. It may even cause death.
And it happens around the country that is why JCAHO mandated that the NPSG
be put into practice. This is the process::
“Ask the patient for his/her name. Repeat the name while
looking at the ID band to compare the stated name. If doing a
procedure that requires labeling, ask the patient for his/her
name. While repeating the stated name, compare the label and
the ID band to make sure the name is correct, and the MR#
match.
2. Reduce injury from falls: Falls prevention we will discuss this later.
3. Responding to clinical alarms.
4. Prevent spread of infection that we already discussed.
B. Falls Prevention: RNs assess patient for falls risk.
Knowing that your patient is at moderate to high risk for falls, how would you care
for this patient. What are your responsibilities a s a PCA: OK. In addition to what
we had discussed earlier, there are additional ways to prevent them from falling.
a. Make hourly patient rounds. When you do your rounds, you go in and ask
the patient if they need anything, food, water, repositioned. Remember the
hourly rounding log? It promotes fall prevention. Hourly rounding will be
done for everyone.
b. Offer toileting, use the toileting schedule that is being successfully used in
R3S, R4N. Offer bedpan, urinal or offer to assist the patient to walk to the
bathroom before and after each mealtime, before you get off work. When do
you think patients fall more often. Yes early in the morning. You know
why? To urinate. So the scenario might be, they just woke up, need to go
right away, rushed to the bathroom, the room is cluttered, the patient still
dizzy from the effects of medication, so where would you find the patient?
You are right, on the floor hopefully not having a fracture.
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c. What else can we do especially for those who like to be independent but
disoriented, unsteady and keep getting in and out of bed or chair? ………
You try and move their bed close to the nurses station, you can even take the
patient to sit with you by the nurses station, give them a book to read or
towels to fold..
Use the Tabs Bed Monitor Alarm. Test to make sure there is battery, the
pads sensors are in proper working order. The alarm will be very loud and that is
the whole point. You want to hear it and get to the patient right away before the
fall.
Well now, you know you have done everything you could possibly do and the patient
still fell. How would you take care of a patient after a fall or, let’s say, you found the
patient on the floor, what would you do?
Taking care of the patient after a fall: The patient may be seen actually falling,
found on the floor or report that he/she fell.
a. Do not leave the patient, instead call for help.
b. Do not move the patient until the RN or the physician had assessed the
patient and found the patient safe to be moved.
c. Ask for assistance to move the patient back to bed, even if the patient is
awake and seem strong enough. Remember, the patient just fell.
d. Check vital signs and repeat at frequent intervals as assigned by the RN.
e. Observe the patient for changes in behavior, change in mental status or level
of consciousness, report of pain. Report your observations to the RN.
C. Safe use of restraints.
What is a restraint?
1. Definition of restraints: A restraint is anything that prevents a person from
complete freedom to move about or touch his body part. A physical restraint is any
device placed on the body or near the body that prevents a person from complete
freedom to move about.
2. SJHS philosophy regarding the use of restraints: to be a restraint free environment,
to reduce the use of restraints, to reduce the length of time patient uses restraint, to
use alternatives including asking family member to sit with the patient.
3. What alternatives can you use in order to avoid the patient from being restrained?
Alternatives to restraints include: limb immobilizer, close supervision, removal of
equipment or device that is not needed anymore and causing the patient agitation
due to lack of understanding, and keeping the room quiet.
4. Why do we use restraints? Reasons for restraints: Restraints are used to keep the
patient from puling tubes and lines that is necessary to provide medical treatment.
To protect the staff, visitors and other patients from violent actions of a patient. To
help a confused or disoriented patient to get medical treatment or help and is not
cooperating. Patient is uncooperative and need to be adequately assessed by the
physician while under the influence of drug or alcohol and prevent the patient from
leaving the hospital and they may hurt someone or themselves.
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5.
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8.
The use of restraints requires a physician’s order. You will be asked to help
apply the restraints. It is important that you know how, because improper
placement can cause very serious injuries. So, if you had attended a class and
forgot how, ask the RN to show you and then observe you. After you had
demonstrated that you can apply it properly (met Competency), you can
independently release and re-apply restraints. Remember when patient are
restless or agitated you will need 2 staff members and sometimes even more
put on the restraint.
Do not release the restraints if you know the patient is still a danger to himself
and others. Inform the RN.
Types of physical restraints: vest, soft padded wrist restraints, mittens, 4 side rails
up, except when requested by the patient or family, in The ER and R2 (psych)they
also order the use the synthetic leather restraints.
PCA responsibilities: Every 2 hours PCA will: Provide care to patients on
restraints. Release restraints one limb at a time and provide ROM if able, Provide
skin care, reposition, give daily baths. Offer food, water and toileting. Ambulate
the patient if possible. Report activity and observations to the RN. Report any
discoloration, abrasion or skin tear that you might observe at the areas where
restraints are applied. At times patients in R2 will be in seclusion, at times on
synthetic leather: observations and patient care interventions will be done every 15
minutes. If any of the patient care is not possible, notify the RN. Depending on the
type of restraint s being used, you may be asked to check on the patient every 15
minute.
When restraints are in use, continue to maintain the patient’s right to dignity and
provide the patient the best possible care. Observations are done frequently to
make sure the patient is safe and not in danger of getting hurt while they have the
restraint on.
What are the complications of restraints? Restraints can cause loss of circulation if
it is too tight, limb dislocation, limb fracture, infection, psychological problems,
even death. Always make sure you are doing assigned responsibilities and always
report to the RN your observations.
D. Our next topic for discussion is Pressure Ulcer prevention:
Remember that as PCA you should know that anyone who must stay in bed, chair or
wheelchair because of illness or injury, or who cannot change position without help is at high
risk to develop pressure ulcers. Pressure ulcer can develop in a matter of hours. A pressure
ulcer is an injury caused by constant pressure to the skin and muscle / and or by
shearing/rubbing forces. When person cannot change position, pressure closes tiny blood
vessels that nourish the skin and supply oxygen. When the skin lacks nutrients and oxygen
for too long, the tissue die and pressure ulcer forms. Development of pressure ulcer means
poor nursing care.
1. Pressure ulcer prevention strategies: So how can we prevent pressure ulcers?
a. Change position every 2 hours while patient is in bed. More frequently if
needed. Nobody should be left in one position for more than 2 hours. Some
people can not be fully turned and it is OK to tilt them to relieve pressure.
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b. If the patient is able, ask the patient to shift position while sitting in a chair
every 15 minutes. If not able to shift position, ask someone to help you and
have the patient stand up completely off the chair every hour, then sit back
down.
c. Keep the incontinent patient clean and dry. Change the sheets as soon as it
get wet. Use moisture barrier cream.
d. Do not massage reddened areas.
e. Do not use diapers.
f. Relieve heel pressure (off-load the heels). If the patient can not move, heels
must be raised off the bed. Pillows should be placed under each leg from
mid-calf to ankle, not behind the knee.
g. Do not use donut-shaped cushions. It cuts off blood flow and causes tissue to
swell.
h. Reduce shear forces and friction. Shearing is also a kind of pressure injury.
It happens when the skin moves one way and the bone underneath moves
another way. Sources of shearing are: dragging the patient across the bed
sheets. Allowing the elbows and heels to rub against the bed surface, raising
the HOB more than 30 degrees, which increases shearing forces over the
lower back and the coccyx.
i. To reduce shear forces or friction: Lift the patient to reposition the patient.
Do not drag the body across the bed sheets.
j. Keep HOB no more than 30 degrees unless specifically ordered by the
physician.
k. Do not massage bony prominences. Use elbow pads or sheepskin boots to
reduce friction on heels and elbows.
l. Cleanse gently when washing the patient.
m. Avoid rubbing or scrubbing the skin.
n. Encourage the patient to eat nutritious food. Report patient food intake.
2. Stages of pressure ulcers: (This is only for your reference during the discussion
about the poster board on pressure ulcers.) Ulcers are classified according to
the severity of the wound. Several stages of the wound can be present at the same
time.
a. Stage 1: the skin is intact but shows a persistent pink or red area that does
not turn white when you press it with your finger. For brown skin tone, the
color may be bluish; for dark skinned it may be purplish discoloration. The
affected skin may be painful, itchy, or tender. It may feel warm, spongy or
firm to touch.
b. Stage 2: the skin starts to breakdown and there is a partial thickness skin
loss. The wound looks like an abrasion, a blister or a shallow crater. It can
usually be treated successfully and heal quickly if given quick attention..
Development beyond stage 2 tends to indicate lack of aggressive and timely
intervention.
c. Stage 3: the skin has broken down and extends through all layers of the skin.
May require treatment up to 1 year and now becomes the primary site of
infection.
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d. Stage 4: there is full thickness skin loss with involvement of muscle,
underlying organs, bone and tendons. Surgery is the normal course of
treatment.
Your patient has a pressure ulcer, how will you take care of this patient?
3. Care of a patient with pressure ulcers. The basic treatment for pressure ulcer is
prevention. If a patient has pressure ulcer, inspect if dressing is intact, loose, soiled
and inform RN so dressing can be changed. Reposition patient and if unable to
turn due to pressure ulcer, patient may be tilted to the side. That way pressure is
relieved from the bony areas. A tilt is better than not being repositioned at all.
Patients on special mattresses still need to be repositioned. Keep track of patient
food intake. Encourage protein intake. Keep incontinent patient dry and clean.
Change the sheet as soon as it gets wet. Use moisture barrier cream. No diapers
unless ambulating or transporting to other department for procedure. Do not
massage reddened area. Off load the heels. Avoid shearing forces. Follow
prevention strategies.
V. Communication: Ask the group: If a patient was transferred to your floor from critical care unit
or from another floor, would you know if the patient is at risk for falls, or not allowed to eat yet or
on intake and output? So how would you know these things? What do you expect from an RN to tell
you during report at the start of the shift or when a patient is newly admitted to your floor? You will
be hearing more about hands-off of care. It means reporting or getting report from someone
regarding your patient’s needs and provide safe environment for the patients. The language barrier,
fall risk, IV tubings, surgical tubings and catheters. and equipment in use must be communicated to
the receiving department. So it means that if ever you transported a patient in radiology and the
patient is on fall precaution on your floor, Do Not leave the patient alone on a stretcher without
endorsing the patient and having someone there to receive the patient. You must tell the tech that the
patient is on fall risk. If your patient has a foley catheter, it is important to tell everybody who is
helping you get the patient OOB, so everyone will be careful not to get it accidentally pulled or
disconnected. Again, it is important that you report to the RN abnormal vital signs, abnormal skin
findings, how much food the patient is eating, the way the patient walks, the weight gain or weight
loss, and any patient observation that concerns you.
VI. Infection: How many of you know the word nosocomial? So, how do we prevent the spread
of infection? By Handwashing. You can also use the alcohol base waterless hand hygiene products
except for C-Diff. If you are caring for a patient with C-Diff, you must WASH your hands With
SOAP and WATER. If you see signs outside the patient door, read it.., as it may be an infection
control sign that dictates the PPE (personal protective equipment) you must wear.
VII. Responding to clinical alarms: IV infusion pumps, BP machine, with alarm limits set and
placed on a patient at a set frequency, feeding pumps and cardiac monitors have alarms to alert
caregivers that something is wrong. When you hear the alarm, notify the RN immediately. PCAs,
technicians, nurse’s aides are not allowed to manipulate, not allowed to adjust and not allowed to
turn off the machine. You are not allowed to reset the alarm. Notify the RN immediately.
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General safety: Perform the five (5) checks before leaving the patient’s room.
1. Check to see if side rails are up. Med/Surg and Telemetry, 2 side rails at the HOB
will be kept up as controls of bed and TV are on it. Is bed the same as when you
entered? I.e., HOB up if tube feeding in place.
2. Is bed in the lowest position?
3. Is patient comfortable and in good alignment?
4. Are call bell and supplies within reach?
5. Are wheels of bed locked/brakes in licked position?
Remember the Three (3) P’s when making patient rounds or responding to patient calls.
1. Pain: Ask if they are in pain, sore or uncomfortable. Ask what you can do to help
ease the pain or discomfort.
2. Potty: Ask if they need to go to the bathroom, use a urinal or a bedpan.
3. Position: Are they in good position? Do they need to be pulled up? Is it time to
reposition?
VIII.
IX. Hourly Rounding log: Why do patients use their call lights? It is frequently used and the
most common reasons for call lights use are: bathroom/bedpan assistance, IV problems/pump
alarms, accidental call, pain medication, nurse or PCA/NA needed, repositioning, mobility
assistance. With hourly rounds it was found that call light use decreased, there is increase in
patient satisfaction, significant improvement in patient safety as measured by the frequency of
patient falls, pressure ulcers are reduced. Because of these significant findings, SJHS adapted it
and now being put in place. Patients feel assured that someone will be attending to their needs.
They feel secure just knowing that in the next hour, someone will be doing rounds to check on
them, someone they could trust and rely on.
References:
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AJN: Effects of Nursing Rounds, Sept. 2006 by Meade, M.C., Bursell, L.a., Ketelsen, L.
Sorrentino, S. A., Mosby’s Textbook for Nursing Assistants. 5th ed.
SJHMC policy/procedure
Nursing Assistant Education. htm (2001-2003 Alene Burke)
www.studergroup.com
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