Nursing Hazards

Hazards of all types can exist in healthcare facilities and organizations must take steps to identify and control these hazards� Conducting periodic tours, inspections, and surveys can help identify and control hazards� Organizations with established safety cultures can rely on staff vigilance to help identify hazards and prevent accidents� Healthcare supervisors must also focus on correcting unsafe acts and behaviors� Facility personnel at all levels should learn to observe hazards and behaviors that could contribute to accidents� Senior leaders should stress the importance of job safety education and training� Supervisors should communicate the need for personal involvement in safety and hazard control efforts�

(Continued)

BOX 3.1 NURSING SAFETY RESPONSIBILITIES

• Advise leaders, supervisors, and the safety committee about hazards and safety issues • Use good communication and human relations skills to help achieve safety objectives • Seek ways to help in the development, implementation, and maintenance of safety plans • Promote safety awareness throughout the nursing unit and the organization • Get involved with organizational hazard surveys and environmental tour efforts • Provide input and suggestions that address the development and evaluation of safety

training • Understand the importance of timely accident reporting, investigations, and hazard

analyses • Ensure compliance with safety and fire regulatory standards and codes • Participate in organizational root cause analysis sessions as necessary to identify

causal factors • Attend professional education sessions to stay current with healthcare safety and

health issues • Consider earning healthcare safety-related certifications • Understand the requirements of accreditation standards and regulatory compliance • Promote patient safety as an integral part of the total organizational safety system

BOX 3.2 BASIC SAFETY TIPS FOR NURSES

• Follow good hygiene and handwashing practices when exposed to hazardous substances

• Use proper devices, equipment, and techniques to prevent needle stick and sharps injuries • Properly select and use required personal protective equipment (PPE) and other appro-

priate barriers • Adhere to safe patient moving and lifting techniques, including the use of assist devices

Many healthcare organizations overlook the administrative areas during safety surveys� These areas contain a number of hazards including lifting, climbing, repetitive motions, tripping, electrical hazards, and others� Office areas can also experience workplace violence in locations such as admissions, emergency departments, gift shops, patient affairs, and business offices� This section briefly addresses some common hazards found in administrative areas� Healthcare personnel must learn to close desks and filing cabinet drawers after every use� Take actions to ensure electrical cords and wires don’t create walkway hazards� Ensure aisles and passageways remain clear at all times� Do not permit individuals to use furniture or chairs to reach overhead items� Establish cleanup procedures for spills and communicate that everyone must take responsibility for reporting loose carpeting or damaged flooring� Prohibit the placement of storage boxes and other materials on top of storage or file cabinets� When storing materials, place heavy items at the lowest level possible to prevent overreaching� Keep fire extinguishers accessible and emergency egress routes unobstructed� Never permit the storage of materials closer than 18 inches from fire sprinkler heads� Provide a good lighting system that supports the tasks being performed� Take actions to minimize glare from ceilings,

BOX 3.3 NURSE SAFETY EDUCATION TOPICS

• Bloodborne pathogens and healthcare infection risks • Standard precautions and handwashing requirements • How to select, use, maintain, and store personal protection equipment (PPE) • How to select the proper footwear and other protective clothing • Methods and engineering innovations for preventing needle stick injuries • Patient and material handling or lifting techniques • Detailed information about shift work and sleep deprivation • Protections to take against workplace violence • How to work safely with compressed gases • Importance of following established safety procedures • Emergency response, egress, and evacuation procedures • Accident, incident, hazard, and injury reporting procedures • Hazard communication about chemicals and hazardous wastes • Location, availability, and use of chemical Safety Data Sheets • Medical equipment procedures and adverse event reporting • Patient safety issues including organizational and clinical topics

BOX 3.2 BASIC SAFETY TIPS FOR NURSES (Continued)

• Avoid awkward positions when moving patients and take frequent breaks for repetitive tasks

• When working second and third shifts, develop proper sleep and diet patterns • Learn to identify hazards associated with various shifts or job assignments • Seek assistance from organizational sources to deal with job-related stress • Help keep all corridors and other passages clear of clutter and equipment • Practice good electrical safety in the performance of all duties • If exposed to radiation, follow established procedures and wear a monitoring device • Learn to identify safety hazards including fire prevention

walls, and floors� Clean and replace old bulbs and faulty lamp circuits� Never position workstations facing windows, unshielded lamps, or other sources of glare� Take actions to protect personnel from noise generated by video display terminals, copiers, telephones, fax machines, hallway pedestrian traffic, and break areas� Identify electrical hazards posed by faulty equipment, unsafe installation, or misuse of equipment� Ensure the proper grounding of equipment and machines that could pose a shock hazard� Provide sufficient outlets to eliminate the need for extension cords� Position all floor outlets carefully to prevent the creation of tripping hazards� Inspect all electrical equipment and cords regularly� Repair or replace defective, frayed, and improperly installed cords� Never store anything in front of electrical panels�

Healthcare organizational leaders, supervisors, and safety personnel should realize that shift work and sleep deprivation affect not only task accomplishment, but also personal safety� People function best during daylight hours� Performance is decreased during periods of rapid eye movement (REM)� This REM sleep is known as the dream period and normally occurs in the early morning hours� During this period, the body temperature is at its lowest� Humans have what is called “circadian rhythms” or a 24-hour body clock� This body clock can vary with individuals but can also receive undue influence from environmental factors� Shift work and lack of sleep can contribute to health problems or the increased risk of health problems� Shift workers tend to experience high stress levels and family problems� Healthcare organizations should strive to make shift work safer and educate workers on adjustment strategies� Supervisors should know how to evaluate workers� They must look for the signs of sleep deprivation, stress, and fatigue� Evaluate the relationship between work shifts and personal health� Some factors to consider include the time and length of the work shifts, scheduled days off, demands of the job, personal characteristics, and work environments� Working extended hours increases exposure to environmental, chemical, biological, ergonomic, and psychosocial hazards� Research indicates bright lights in work settings can improve worker alertness� Some studies indicate that power naps of no more than 35 to 40 minutes in length can increase alertness during the sleepiest times of a shift� Taking a short nap before a late night shift can help a person stay alert and awake� Sleepiness occurs most during night shifts� Poor daytime sleeping habits of many shift workers contributes to their on-the-job sleepiness� However, sleeping during the day can interfere with social and family activities� Personnel working long or extended shifts must consider ways to better cope with fatigue, lack of sleep, and family situations� The Institute of Medicine recommends that nurses work no more than 60 hours in a seven-day period and no more than 12 hours on single day� Most nurses working 12-hour shifts tend to lose alertness during the last two hours of their schedule�

BOX 3.4 SLEEP DEPRIVATION EDUCATIONAL TOPICS

• Stress the importance of getting six to seven hours of uninterrupted sleep • Explain the importance of sleeping in a dark room free from distractions • Provide tips on how to deal with noise during sleep periods • Encourage the eating of a nutritious meal during the shift • Avoid caffeine late in a shift since it disrupts sleep patterns • Address the importance of exercising on a regular basis

Nurses experience stress complicated by understaffing, paperwork, tight schedules, equipment malfunctions, demanding families, dependent patients, and even death� Some workers feel that the depersonalized nature of healthcare leaves them feeling alone, isolated, angry, and frustrated� Stress contributes to worker apathy, lack of confidence, and absenteeism� Studies have shown that healthcare workers have a high rate of hospital admission for mental disorders� Stress can cause loss of appetite, mental disorders, migraines, sleeping disorders, and emotional instability� It can also increase the use of tobacco, alcohol, or drugs� Stress can affect a person’s attitude, motivation, and behavior, which can impact the quality of patient care� Healthcare organizations should educate employees and management about job stress by establishing employee assistance initiatives and organizational change education sessions� Employee assistance initiatives can improve the ability of workers to cope with difficult work situations� Stress management plans should focus on teaching workers about the nature and sources of stress, the effects of stress on their health, and learning personal skills that can help reduce stress�

Occupational Safety and Health Administration (OSHA) Standard 29 CFR 1910�22, WalkingWorking Surfaces, and ANSI A1264�2-2006, Standard for the Provision of the Slip Resistance on Walking/Working Surfaces, provide guidance on preventing slips, trips, and falls� Safety personnel must identify, evaluate, and correct any hazards that could contribute to these types of events�

BOX 3.5 COMMON HEALTHCARE NURSE STRESS FACTORS

• Understaffing and unbearable workload • Inadequate resources to accomplish the task • Working in an unfamiliar area, job, or role • Rotating work shifts or shifts longer than eight hours • Little or no input or participation in schedule planning • No recognition by senior leadership for doing a good job • Personal talents and expertise not utilized • Exposure to biological, physical, and chemical hazards • Increased potential for workplace violence • Poor departmental or unit organization

BOX 3.6 WAYS TO COPE WITH STRESS

• Conduct staff meetings and allow open communication • Implement a formal stress management plan • Provide accessible counseling from a nonjudgmental source • Promote flexibility and creativity within the department • Ensure adequate staffing and sufficient resources • Organize work areas and departments to function efficiently • Work to provide reasonable and flexible work schedules • Emphasize the importance of worker safety and health • Provide regular in-service education and training sessions • Implement a complaint and suggestion system

Educate staff members about the causal and behavioral aspects of fall prevention efforts� Establish procedures to analyze trends related to slip and fall incidents� Slip, trip, and fall incidents can frequently result in serious disabling injuries� Slips and falls can result in lost workdays, reduced productivity, expensive workers’ compensation claims, and diminished ability to care for patients� In 2009, the Bureau of Labor Statistics (BLS) reported a hospital incidence rate of 38�2 per 10,000 employees for slips, trips, and falls occurring on the same level� The 2009 rate was 90% greater than the average rate for all other private industries combined� These events resulted most often in sprains, strains, dislocations, and tears for healthcare personnel, including nurses� Contaminants on the floor contribute to most healthcare facility slip, trip, and fall incidents� Implementing effective housekeeping procedures, conducting proper floor cleaning, using walk-off mats, posting safety signs, and requiring the wearing of slip-resistant shoes minimize the risk of slipping�

OSHA Standard 29 CFR 1910�145 addresses accident prevention signs and tags� These specifications apply to the design, application, and use of signs/symbols used to prevent accidental injuries or property damage� These specifications do not cover plant bulletin boards, safety posters, or any signs designed for streets, highways, railroads, or marine applications� OSHA standards do not address sign design for Danger, Caution, and Safety Instruction signs except for purpose and colors� OSHA requires that signs be designed with rounded or blunt corners; they must be free from sharp edges, burrs, splinters, or other sharp projections� The ends or heads of fastening devices cannot create a hazard� The size of the sign, height and width of the letters, and viewing distances must meet ANSI Z535�2 requirements� Ensure signs contain concise and easy-to-read wording� Use letters large enough to meet determined intended viewing distances� Place signs in locations so that individuals can take action to avoid the hazard� Use legible signs that do not cause distraction or create a hazard� Never place signs on moveable objects or adjacent to moveable objects such as doors and windows� If necessary, equip signs with emergency or battery-operated illumination� OSHA Standard 29 CFR 1910�144 requires the use of red to mark fire protection equipment and apparatus� Use red danger markings for safety cans or other portable containers of flammable liquids, excluding shipping containers� Red safety cans must contain some additional clearly visible identification either in the form of a yellow band around the can or the name of the contents conspicuously stenciled or painted on the can in accordance with 1910�1200� OSHA mandates the use of yellow as the basic color for designating caution� Use yellow for the marking of physical hazards such as striking against, stumbling, falling, and getting caught in between�

OSHA now considers the National Electrical Code (NEC) or National Fire Protection Association (NFPA)/ANSI 70 as a national consensus standard� Article 517 of NFPA 70 contains special electrical requirements for healthcare facilities� Refer to 29 CFR 1926�401-449 for OSHA construction-related electrical requirements� In addition, state and local regulations may apply� Electricians and maintenance personnel must understand OSHA electrical safety standards published in 29 CFR 1910�301-399� NFPA/ANSI 70 applies to every replacement, installation, or utilization of electrical equipment� Supervisors must inspect work areas for possible electrical hazards� Electrical current travels through electrical conductors; its pressure is measured in volts� Resistance to the flow of electricity is measured using ohms, which can vary widely� Resistance determination considers the nature of the substance itself, the length and area of the substance, and the temperature of the substance� Some materials, like metal, offer very little resistance and become conductors very easily� Other substances, such as porcelain and dry wood, offer high

resistance� Insulators prevent the flow of electricity� Water that contains impurities such as salts and acids make a ready conductor� Electricity travels in closed circuits and follows its normal route through a conductor� Electrical equipment can cause shock, electrocution, and catastrophic property damage due to fire or explosion risks� Electrical fires in healthcare facilities many times result from short circuits, overheating equipment, and failure of current safety devices� Explosions may occur when flammable liquids, gases, and dusts interact with ignition sources generated by electrical equipment�

The OSHA Bloodborne Pathogens Standard requires workers to take precautions when dealing with blood and other potentially infectious materials (OPIM)� Implement engineering and work practice controls to eliminate or minimize exposure to bloodborne pathogens� Engineering controls can reduce employee exposure either by removing, eliminating, or isolating a hazard� Ensure employees wear appropriate PPE or clothing such as gloves, gowns, and facemasks�

Ensure employees properly discard contaminated needles and other sharp instruments immediately or as soon as feasible� Consider all blood and other potentially infectious body fluids as infected� The Bloodborne Pathogens Standard does allow healthcare organizations to use acceptable alternatives to Universal Precautions� Consider using Centers for Disease Control and Prevention (CDC) Standard Precautions or Body Substance Isolation techniques as appropriate for the setting� Safer needle devices must contain integrated safety features designed to prevent needle stick injuries� OSHA considers safer needle devices as passive or active� Passive needle devices offer the greatest protection because they contain safety features that automatically trigger during use� For example, consider a spring-loaded retractable syringe or self-blunting blood collection device� Intervention studies show that the use of safer needles systems can reduce injuries�

Hazardous chemical exposures can occur from aerosols, gases, and skin contaminants� Exposures can occur on an acute basis or result from chronic long-term exposures� Some substances commonly used in the healthcare setting can cause asthma or trigger attacks� Studies indicate scientific evidence linking cleaners and disinfectants, sterilants, latex, pesticides, volatile organic compounds, and pharmaceuticals to asthma� Many medications and compounds used in personal care products have known toxic effects� Although many medications pose hazards to workers, those most commonly identified as hazardous to healthcare workers include antineoplastic drugs and anesthesia substances� Anesthetic gases can pose problems when escaping and can create occupational inhalation hazards�

A recent survey of nurses and physicians revealed that about three-fourths of the respondents reported witnessing physicians engage in disruptive behaviors� Most of the incidents involved verbal abuse of another staff member� OSHA considers these types of issues as workplace violence� The same survey revealed that about two-thirds of respondents witnessed disruptive nurse behaviors� Most respondents believed that such unprofessional actions increase potential for medical error occurrence� Disrespectful behavior and in some cases, physical violence by physicians, can contribute to nursing dissatisfaction� Physicians practicing in high-stress specialties such as surgery, obstetrics,

and cardiology appear more at risk to disruptive behaviors� The Joint Commission requires that organizations develop a code of conduct policy for all staff� The Joint Commission also recommends a “zero tolerance” approach to all disruptive behaviors� It issued a Sentinel Alert to address the seriousness of these risks� Patient and family assaults on healthcare workers can occur, especially during times of increased stress� Poor workplace security and unrestricted movement by the public in the facility can increase these types of risks� Emergency department personnel also face significant risks from assaults by patients or their families� Those carrying weapons in emergency departments create the opportunity for severe or fatal injuries� However, no location within a healthcare setting is immune from workplace violence� The OSHA publication Guidelines for Preventing Workplace Violence for HealthCare and Social Service Worker, provides an outline for developing a violence prevention plan� Develop performance-based violence prevention plans� Facilities must meet the challenge of developing a specific process that will yield results and protect healthcare personnel� The elements of any prevention plan must include management commitment, employee involvement, worksite analysis, hazard prevention and controls, and training and education�

Many acute care and trauma facilities receive patients brought in by helicopters� Staff responsible for meeting these airborne ambulances must know proper safety procedures� Restrict the heliport to trained and authorized personnel� Personnel should never approach the landing zone until the craft lands� Wait for crew permission before approaching the craft� Require the wearing of hearing protection when aircraft engines are running� Prohibit smoking in the heliport area� Personnel should never shine lights directly in front of the aircraft during landing� Approach the craft from the front or side as required, but never approach from the rear� Stay in a crouched stance when approaching the aircraft� The wind created by the rotor blades can create hazardous situations due to flying dust, litter, and loose clothing� Place stethoscopes in pockets and secure hats or scarves� Tape sheets securely to the stretcher� Place the portable oxygen bottles so that they do not extend beyond the cart� The flight crew retains responsibility for opening and closing the aircraft doors� In most situations, the flight crew takes responsibility for offloading the patient� The flight crew should direct hospital personnel on proper patient handling� They also provide directions about departure from the heliport� Not following instructions could result in an intravenous line being pulled or a change in the patient’s skeletal alignment� Offloading with the rotor blades turning requires caution at all times� Ensure the availability of sufficient fire extinguishers and that all personnel can operate the extinguishers�

Volunteers work in a variety of capacities in most healthcare organizations� Each volunteer needs training and education on all potential exposure risks� Many organizations limit volunteers from patient contact tasks that could expose them to hazards, including bloodborne pathogens� Healthcare organizations using volunteers should provide a comprehensive safety orientation session� Some key education topics should include fire safety, emergency evacuation procedures, infection control precautions, patient safety topics, radiation exposure controls, general safety orientation, hazard identification, and accident reporting procedures�

Nurses who provide in-home care to patients face many of the same on-the-job safety concerns as their colleagues who work in controlled facility environments, like a hospital� Universal safety concerns for nurses include needle sticks, musculoskeletal injuries, verbally or physically aggressive patients or family members, and driving to and from a job located in a neighborhood with

higher than average crime-related incidents� Safety concerns that are unique to working in a home environment may include traveling from home to home, encountering pets, observing drug use, or walking on poorly maintained sidewalks to a patient’s home� Providing care in a small space and lifting without the convenience of an adjustable-height bed or mechanical lift can create challenges�

Proper safety for the home healthcare nurse and patient should begin with a thorough assessment of the home to identify potential risks� Prior to the patient’s discharge from the facility, someone should complete the assessment and develop a plan to mitigate or eliminate any risks� Patient and family education about maintaining equipment and a hazard-free environment will help facilitate a safe environment for all� Expert training can equip home healthcare nurses with the ability to assess and manage safety risks� Annual safety training and ongoing in-service education should include personal protection techniques, fire safety, body mechanics, infection prevention measures, proper use of equipment, and instruction on how to report any suspicious or threatening behaviors within the home setting� Agencies must provide ongoing clinical supervision and support for all personnel night and day�

Notify your agency if PPE supplies are low in the patient’s home� Home healthcare industry personnel encounter a number of hazards not found in traditional healthcare settings� They spend a great deal of time traveling and entering environments where they have little or no control� Many patients live in unsafe neighborhoods that could expose providers to violence� However, home healthcare providers are exposed to bloodborne pathogens and patient moving hazards much like their hospital counterparts� Nursing aides, nurses, and therapists often work alone with no one to support them in a time of crisis� Home-based healthcare remains unpredictable and the agency must take responsibility for worker safety� Home health personnel must ensure care plans identify hazards and care requirements� Use well-lit and common walkways when visiting patients� Instruct patients and family members on the importance of infection control� Always knock or ring the doorbell before entering a patient’s home� Know injury and emergency reporting procedures and learn to document unsafe behaviors, threats, and menacing pets� If possible, schedule joint visits in unsafe neighborhoods or homes� Always request security escorts for night visits in potentially unsafe areas� If threatened, home health personnel should scream, kick, and use chemical spray or a whistle� Lock automobiles and keep them in top mechanical condition� Park vehicles as near to the patient’s home as possible�

BOX 3.7 HOME HEALTH SAFETY TIPS

• Know the surroundings and stay alert when traveling to and from a patient home� • Obtain accurate directions and addresses� • Park your car in a well-lit area, away from trees or bushes� • Notify your employer if you feel threatened or have concerns about personal safety� • Keep all medical supplies out of view and locked in the trunk of your car between

visits� • Use mechanical lifting devices, if available, when transferring your patients� • Use proper body mechanics when lifting household items or manually transfer-

ring your patient� Keep knees bent, feet apart, and the object or patient close to your body�

• Notify the employer about safety issues related to lifting and transferring a patient� • Always keep extra supplies of PPE, including gloves, gowns, eye protection, and

masks, in your car or travel bag�

All personnel should know the location of all emergency equipment� This includes drugs, cardiac arrest equipment, and resuscitators� Ensure the use of explosion-proof electrical equipment and plugs�

Develop written schedules of inspections and maintenance of all electrical equipment� Operating room personnel should receive annual training on bloodborne pathogens and other safety issues� Implement policies and procedures for sharps injury reporting� OSHA requires an appropriate sharps safety plan that includes the evaluation and selection of safer sharps and needles� Operating rooms must document the evaluation of commercially available safety products such as safe suturing devices, safety needles, safety scalpels, sharps, and passing containers� Offer a Hepatitis B vaccination series at no cost to employees with exposure to blood or OPIM� The surgical staff must maintain a sharps injury log that includes the type and brand of device involved in an exposure, the work area where the exposure occurred, and an explanation of how it happened� Minimize the hazards of exposures in surgery suites by promoting the use of

• Safer needles and other sharps devices • Blunt suture needles • Needleless IV connectors • Proper containerization of sharps • A no pass zone for surgical instruments

The Centers for Medicare & Medicaid Services (CMS) recently decided to change the minimum hospital operating room relative humidity from 35 percent to 20 percent� CMS currently requires hospitals to comply with the 2012 edition of NFPA 101: Life Safety Code®� That edition references the 1999 edition of NFPA 99: HealthCare Facilities Code, which requires operating room humidity to be at least 35 percent� This Life Safety Code waiver CMS permits hospitals to keep operating room relative humidity level at a minimum of 20 percent� A most recent edition of NFPA 99 shifted to a minimum requirement of 20 percent humidity� The waiver does not apply if more state or local laws/regulations have more stringent requirements� Facilities must monitor relative humidity levels in anesthetizing locations and must take action to ensure levels remain at or above 20  percent� Facilities that elect to use this categorical waiver do not have to apply in advance� However, they must document their decision to use the waiver�

Chemicals employees could be exposed to in surgical facilities include peracetic acid, used in cold sterilizing machines, and methyl methacrylate, used to secure prostheses to bone during

BOX 3.8 HOME HEALTH WORKER TRAINING TOPICS

• Understanding the patient’s age and cultural, economic, and social factors • Disease manifestations • Mental, emotional, and spiritual needs • Personal security precautions, including travel safety • How to conduct a hazard assessment during a consultation visit • Protection guidelines for bloodborne pathogen exposure • Sharps and needle safety precautions • Medical waste disposal procedures • Back injury prevention techniques • Safe lifting and transfer techniques • Care plan development to identify risks

orthopedic surgery� Recommend mixing methyl methacrylate only in a closed system� Employees should carefully read and follow instructions and warnings on labels� Employees should follow all Safety Data Sheet (SDS) instructions regarding safe handling, storage, and disposal of hazardous chemicals� According to the Hazard Communication Standard, employers must inform employees of chemical hazards and have on hand SDSs for all hazardous chemicals used in their facilities�

Staff is at risk of trip and fall hazards such as falling over portable equipment that easily blends into the floor or slipping on debris� Electrical cords crossing floors can create trip hazards� OSHA requires that work areas are kept clean, orderly, and in a sanitary condition� Keep aisles and passageways clear and in good repair, with no obstruction across or in aisles that could create a hazard� Provide ceiling or floor plugs for equipment, so power cords need not run across pathways� Static postures from continuously standing in one position during lengthy surgical procedures may cause muscle fatigue and pooling of blood in the lower extremities� Standing on hard work surfaces such as concrete can create trauma and pain to feet� Avoid awkward postures such as tilting the head forward for long periods of time� Provide stools where their use is possible� Use shoes with wellcushioned insteps and soles� Provide a footrest bar or a low stool� Use height-adjustable work surfaces� Ensure that all electrical service near sources of water is properly grounded� Use appropriate PPE and safe work practices for assessed hazards� Develop procedures to routinely monitor the condition of equipment and address work practices of employees�

Recommend a hands-free technique for passing instruments� The National Institute for Occupational Safety and Health (NIOSH) published The Effectiveness of the Hands-Free Technique in Reducing Operating Room Injuries in November 2001� The use of blunt needles when appropriate and suturing devices with needle stick protection offer the highest protection against suture needle sticks� Avoid placing hands unnecessarily near sharps� Surgical personnel should avoid unnecessary handling of sharps� Never hold any sharp simultaneously with another instrument� Contain sharps in designated zones at all times� Never cross the room with a sharps instrument in hand� Some operating rooms use trays or basins where the instrument is placed before being picked up by the second person� Sometimes they use a designated area on a cart or table� Verbally announce the transfer of sharps into the neutral zone� Keep eyes on sharps until placed in designated zones� Use safety transfer trays and magnetic drapes to transfer sharps between nurse and surgeon during surgical procedures� Recent studies indicate that more than 60 percent of scalpel blade injuries were inflicted by the user on assistants, typically during equipment transfer� The thumb and index finger of the nondominant hand commonly experience injury with scalpels and suture needles because they reposition or hold tissue� Develop alternatives including the use of retractors instead of hands, rounded scissors instead of pointed tips, and staples for skin closure, and also use electrocautery instead of standard scissors� Dispose of sharps immediately after use� Make puncture-resistant containers available nearby to hold contaminated sharps� The OSHA Bloodborne Pathogens Standard also requires the discarding of contaminated needles and other sharp instruments immediately or as soon as feasible after use into appropriate containers�

Never bend, recap, or remove contaminated needles and other contaminated sharps except as noted in 29 CFR 1910�1030� Employers must provide readily accessible handwashing facilities and ensure that employees wash their hands immediately or as soon as feasible after removal of gloves� Surgical staff should wear appropriate protective clothing and equipment, which can protect from unwanted fluid splash or sharps injuries� PPE includes gloves, facemasks, soak-proof gowns, impervious boots or shoe covers, face shields, and other eye protection devices� Make safety scalpels with movable shields or retracting blades available to surgeons and other operating room personnel�

Perinatal nurses educate pregnant women about delivery options, nutrition, and other important issues� They also assist during the delivery of babies and help new mothers learn how to bond with their children� Because perinatal nurses work in healthcare facilities, they are exposed to a

number of risks on a daily basis� Assisting with the delivery of babies puts perinatal nurses at risk of coming into contact with blood and body fluids that contain infectious organisms� Using proper handwashing techniques and wearing gloves, masks, and gowns protects perinatal nurses against these organisms� Perinatal nurses use needles and other sharp instruments to assist in the care of pregnant women and the delivery of babies� This puts them at risk for sharps injuries, which occur when a used needle or other sharp object pierces the skin� These injuries increase the risk for exposure to disease-causing organisms found in the blood� Following universal precautions for sharps disposal protects perinatal nurses from this risk� Nurses should never break, bend, or recap needles� Needles, disposable razors, and other sharp objects should also be disposed of in puncture-resistant containers� Perinatal nurses regularly have contact with equipment and tools powered by electricity� Labor and delivery beds have electrical circuits that allow nurses to adjust the height of the bed and the position of the patient to make it easier to deliver a baby� IV pumps and defibrillators also have electrical components� Perinatal nurses must use basic safety precautions to protect themselves and their patients from shocks, burns, and electrocution� Any machine with a damaged cord should be taken out of service until it has been repaired and inspected� A nurse should report any loose wires, electrical shorts, or related problems to a biomedical equipment technician� Nurses should never use electrical equipment while their hands are wet, as this increases the risk for injuries� Surgeons perform Caesarean sections in operating rooms that contain flammable materials� Perinatal nurses are at risk for burns and smoke inhalation if a fire breaks out during one of these procedures� Following safety precautions related to the use of oxygen and anesthetic gases helps prevent these fires and protect workers from fire-related injuries� Perinatal nurses should keep flammable liquids away from oxygen tanks, as oxygen promotes rapid combustion� Operating room personnel should use caution when working with cauterizing tools, endoscopes, lasers, and other electrical devices� Keeping heat sources away from dressings, sponges, gauze, and surgical drapes also reduces the risk of fires� Perinatal nurses come into contact with hazardous substances on a regular basis� Some products used to disinfect medical equipment irritate the respiratory system and burn the eyes� Epinephrine, which is used to treat anaphylactic shock and cardiac arrest, may be fatal if swallowed, absorbed through the skin, or inhaled� Wearing masks and gloves protects perinatal nurses from inhaling or absorbing hazardous chemicals� Nurses should always wash their hands after handling chemicals and medications� Proper disposal of contaminated materials also reduces the risk of contact with dangerous chemicals�

ICU workers experience the risk of exposure to blood, OPIM, and bloodborne pathogens because of the immediate, life-threatening nature of treatment� The Bloodborne Pathogens Standard requires precautions when dealing with blood and OPIM� Engineering and work practice controls must serve as the primary means to eliminate or minimize exposure to bloodborne pathogens� Employees should wear appropriate PPE when anticipating blood or OPIM exposure� Ensure employees discard contaminated needles and other sharp instruments into appropriate containers immediately or as soon as feasible after use� Maintain exposure control plan documentation of consideration and implementation of appropriate commercially available and effective engineering controls designed to eliminate or minimize exposure to blood and OPIM� Treat all blood and other potentially infectious body fluids as infected and take appropriate precautions to avoid contact with these materials� The Bloodborne Pathogens Standard does allow hospitals to practice acceptable alternatives to Universal Precautions such as Standard Precautions or Body Substance Isolation� Intensive care units, particularly neonatal units, may be designed without walls between patient spaces� This may allow employees to unknowingly experience exposure to aerosolized chemicals and x-ray radiation that escapes from neighboring areas� Ensure that all rooms can remove contaminants through normal ventilation means� When using recirculated air, ensure installation of adequate filtering mechanisms� Because of the ICU atmosphere, potential slip and fall hazards exist if water or other

fluids remain on floors� Never permit electrical cords to run across pathways or place emergency equipment or supplies in passageways� Provide safe cleanup of spills and keep walkways free of obstruction�

Injury may occur to employees from improper training or use of medical equipment� Implement procedures that routinely monitor the status of equipment and proper training of employees to use equipment safely� Workplace violence is an issue in ICUs because of the crowded, emotional situations that can occur with critical patients� Good work practice recommends a security management plan that addresses workplace violence issues� Train staff to recognize and diffuse violent situations and patients� Require reporting of suspicious behaviors� Provide intervention measures including verbal, social, physical, and pharmacological interventions� Warning signs of anger and violence include (1) pacing and/or restlessness, (2) clenched fist, (3) increasingly loud speech, (4) excessive insistence, (5) threats, and (6) cursing�

Studies suggest work stress may increase a person’s risk for cardiovascular disease, psychological disorders, workplace injury, and other health problems� Early warning signs may include headaches, sleep disturbances, difficulty concentrating, job dissatisfaction, and low morale� Ensure workloads remain in line with workers’ capabilities and resources� Design jobs to provide meaning, stimulation, and opportunities for workers to use their skills�

Emergency department personnel experience continuing risks for exposure to blood, OPIM, and bloodborne pathogens because of the immediate, life-threatening nature of treatment� Employees can be exposed to hazardous chemicals or hazardous drugs� Emergency departments should implement approved decontamination procedures� Because of the emergency department’s busy atmosphere, slips, trips, and falls pose a major risk� Provide safe cleanup of spills, and keep walkways free of obstruction� Keep access to exits clear and unobstructed at all times� Injury may occur to employees from improper training or use of equipment such as defibrillators� Electric shock may also occur as a result of lack of maintenance or misuse of equipment� Workplace violence is an issue in emergency departments because of the crowded and emotional situations that can occur with emergencies� Good work practice recommends a security management plan to address workplace violence� Train staff members to recognize and diffuse violent situations and patients� Stay alert for potential violence and suspicious behavior and report it� Provide intervention measures including verbal, social, physical, and pharmacological interventions� Install concealed panic buttons in the department and at triage areas� Install proper lighting and video surveillance equipment� Limit access to the area by implementing a waiting room area with controlled access points� Patients must enter through a secure door� Consider the use of metal detectors to determine if individuals possess weapons of some type� Provide a secure room for patients identified as violent� This room could include controls such as video camera surveillance� Exposure to tuberculosis (TB) and other infectious agents can occur from patients in waiting rooms and treatment areas� Provide and practice early patient screening for TB during admission to identify potentially infectious patients� Provide isolation to prevent employee and other patient exposure� Provide engineering, work practice, and administrative procedures to reduce the risk of exposure� Ask patients with a productive cough to wear a mask to prevent the spread of infection� Post waiting rooms signs that state, “If you are coughing you may be asked to wear a mask�” Isolate patients until verification testing is negative� Some departments provide an isolation room to safely isolate potentially infectious patients� Others can designate an isolation area for infectious patients� Maintain Isolation rooms under negative pressure� Acid-fast bacilli (AFB) isolation refers to a negative-pressure room or an area that exhausts room air directly outside or through high-efficiency particulate air filters (HEPA) if recirculation is unavoidable� Protect employees from exposure to the exhaled air of an individual with suspected or confirmed TB� Isolate patients with suspected or confirmed TB�

Exposure of department personnel can occur from patients exposed to biological agents, chemical agents, and mass causalities as a result of terrorist attacks or events� Provide and plan for emergency response for healthcare employers and emergency responders� The Department of Health and Human Services (DHHS), the CDC, the American Hospital Association (AHA), the Department of Defense (DoD), and OSHA publish resources for hospitals to use when planning for terrorist events�

Hazards present in this unit include exposure to sterilizing solutions and bloodborne pathogens including Hepatitis B� During recent years a number of reports indicate blood contamination incidents related to the internal components of dialysis equipment� The possibility of cross-contamination could permit the transfer of bloodborne pathogens from patient to patient� Under certain conditions, cross-contamination is possible despite the use of new blood tubing sets and external transducer protectors� Please also note that routine maintenance is not adequate to detect internal machine contamination� Qualified personnel should inspect all machines, including the internal pressure tubing set and pressure sensing port, for possible blood contamination� Always use an external transducer protector and utilize pressure alarm capabilities as indicated in the manufacturer’s instructions� If contamination occurs, take the machine out of service� Ensure employees working in dialysis units know the adverse health effects of Glutaraldehyde� Staff should wear proper protective equipment whenever handling sterilizing solutions� Protective equipment should include rubber gloves, protective aprons, and eye and face protection� Appoint a dialysis staff member as the safety coordinator with authority to enforce biological safety policies within the dialysis unit� Require all personnel to follow the requirements of the OSHA Bloodborne Pathogens Standard 29 CFR 1910�1030� Hospitalbased dialysis units should coordinate infection control exposure plans with the hospital infection control function� Refer to the appropriate CDC guidelines for additional information� Appoint a dialysis staff member as the safety coordinator with authority to enforce biological safety policies within the dialysis unit� Isolate patients who are HBsAg-positive in a separate room or unit designated for HBsAg-positive patients if possible� Otherwise, segregate these patients from hepatitis B seronegative patients in a separate area� Assign staff members with the most dialysis experience or best technique to care for the HBsAg-positive patients�

Never use dialysis equipment for both HBsAg-positive and seronegative patients� If this is impossible, make the staff aware that the chance for cross-contamination increases significantly� All patients should receive specific assignments for dialysis chairs or beds and machines� Change linen used on chairs and beds for each patient� Clean chairs and beds after each use� All patients should receive an assigned supply tray including a tourniquet, marking pencils, and antiseptics� Never use clamps, scissors, and other nondisposable items for more than one patient unless autoclaved or appropriately disinfected�

Staff must wear disposable gloves while handling patients or dialysis equipment and accessories� Staff should wear gloves at all times including taking blood pressure, injecting saline or heparin, or touching dialysis machine knobs to adjust flow rates� The staff should never touch any surfaces with gloved hands that will subsequently be touched with bare hands� The staff should wear gloves whenever handling blood specimens and whenever working in the laboratory area� Wearing protective eyeglasses and surgical-type masks during any procedure with potential for spurting or splattering of blood is recommended� Staff should wear gowns or scrub suits at all times and properly dispose of clothing at the end of each day� Follow the housekeeping practices required by the OSHA Bloodborne Pathogens Standard�

Medical equipment management is also known as biomedical equipment management or clinical engineering� It includes the business processes used in interaction and oversight of the medical equipment involved in the diagnosis, treatment, and monitoring of patients� The related policies and procedures govern activities from the selection and acquisition through the incoming inspection, acceptance, maintenance, and eventual retirement and disposal of medical equipment� Medical equipment management is a recognized profession within the medical logistics domain� The medical equipment management professional’s purpose is to ensure that equipment used in patient care is operational, safe, and properly configured to meet the mission of the medical treatment facility� Some medical equipment professional functions include

• Equipment Control & Asset Management • Equipment Inventories • Work Order Management • Data Quality Management • Quality Assurance • Patient Safety and Risk Management • Hospital Safety Planning • Radiation Safety • Medical Gas Systems • In-Service Education & Training • Accident Investigation • Safe Medical Devices Act (SMDA) of 1990 • Health Insurance Portability and Accountability Act (HIPAA)

Healthcare facilities should implement a management plan that promotes the safe and effective use of medical equipment in support of patient care� This medical equipment management plan maintains complete and continuous compliance with the accreditation organization medical equipment management requirements� These requirements help assess and control the clinical and physical risks of fixed and portable equipment used for the diagnosis, treatment, monitoring, and care of patients� The medical equipment management policy includes all of the current medical equipment management requirements, as well as requirements from other care functions that pertain to medical equipment� The management plan consists of policies and procedures designed to address the following components and issues:

• Selecting and acquiring medical equipment • Evaluating and identifying equipment to be included in the plan • Determining scheduled maintenance intervals and procedures • Repairing and maintaining patient care equipment • Performance standards for equipment inspection, scheduled maintenance, and testing • Scheduling inspections, maintenance, and tests on equipment included in the plan • Development of a policy to provide after-hours service • Coordinating and documenting services of manufacturers and third-party providers • Acting on hazard alerts and recalls of medical equipment • Complying with the provisions of the SMDA of 1990 • Reporting and investigating problems associated with failures and user errors • Educating and training operators and maintainers about medical equipment issues • Providing emergency procedures for medical equipment failures

Establish criteria for identifying, evaluating, and inventorying all equipment before placing in use� Management should provide guidance on monitoring and acting during equipment recall situations� Describe processes for managing effective, safe, and reliable equipment� Identify and implement all processes for selecting and acquiring medical equipment� Evaluate the condition and function of the equipment when received� The organization may choose to include all medical equipment in the management plan� Organizations may use any appropriate strategy including predictive maintenance processes, interval-based inspections, corrective maintenance, or metered maintenance to ensure reliable performance� Define intervals for inspecting, testing, and maintaining appropriate equipment� Minimize clinical and physical risks by using criteria such as the manufacturer’s recommendations, risk levels, and current organization experience� Implement processes for monitoring equipment hazard notices and recalls� Develop procedures for monitoring and reporting equipment incidents that must be reported by the SMDA of 1990�

• Maintain an up-to-date inventory of all equipment identified in the medical equipment management plan, regardless of ownership

• Document performance and safety testing of all equipment before initial use • Document maintenance of equipment used for life support consistent with maintenance

strategies to minimize any clinical and physical risks identified in the equipment plan • Document maintenance of non-life support equipment on the inventory consistent with

maintenance strategies to minimize clinical and physical risks • Document performance testing of all sterilizers used • Document chemical and biological testing of water used in renal dialysis based upon regu-

lations, manufacturer’s recommendations, and organization experience

The FDA Modernization Act of 1997 changed medical device adverse event reporting as of February 19, 1998� On January 26, 2000, the Food and Drug Administration (FDA) published in the Federal Register changes to the implementing regulations, 21 CFR 803 and 804, to reflect these amendments and the removal of Part 804� The user facility semiannual reporting requirement has been changed to annual reporting� The annual report is now due on January 1 of each year� Reports can protect the identity of user facilities except in connection with certain actions brought to enforce device requirements under the act� Report to the FDA any of the following: death, serious illness or injury, or other significant adverse experience�

This act requires healthcare facilities to report serious or potentially serious device-related injuries or illness of patients and/or employees to the manufacturer of the device� The FDA wants to obtain important information on device problems� The act applies to all inpatient facilities, ambulatory

BOX 3.9 MEDICAL EQUIPMENT RISK ASSESSMENT CRITERIA

• Equipment function (diagnosis, care, treatment, or monitoring) • Clinical use or application • Maintenance requirements • Equipment incident history

surgery care centers, peri-operative facilities, diagnostic units, and outpatient treatment centers� It does not apply to physician offices� Failure to comply can result in civil penalties� Healthcare workers that provide care, review patient care, repair devices, or provide preventive maintenance must report device-related incidents� The incidents include device failure, malfunction, design problems, user errors, and inadequate labeling� Reporting responsibilities extend to physicians, nurses, allied health professionals, students, and other organizational personnel� Examples of a medical device include an anesthesia machine, pacemaker, heart valve, suture, surgical sponge, wheelchair, hospital bed, catheter, infusion pump, dialysis machine, artificial joint, and implant devices�

Facilities must report medical device events involving patient deaths to the FDA� Report serious injuries caused by devices or in which devices played a role to the manufacturer� The FDA requires that hospitals maintain documentation of all reportable events� Identify the person that completed the investigation and the information used to form an opinion about the causes of the event� When reporting, use the following forms:

• FDA Form 3500, MedWatch Voluntary Reporting • FDA Form 3500A, MedWatch Mandatory Reporting Medication and Device Experience • FDA Form 3419, Medical Device Reporting Annual User Facility Report

The FDA mandates the reporting and tracking of designated devices� The designated devices include vascular grafts, ventricular bypass devices, pacemakers, and implant-type infusion pumps� The FDA requires that the receipt of tracked devices be reported to the manufacturer and that patient demographic and medical information be reported to the manufacturer upon implanting or use of the device within five working days� This enables the manufacturer to trace specified medical devices to patients and to facilitate patient notification and/or device recall�

Healthcare facilities must establish a zero tolerance philosophy regarding personnel and property security, including physical violence� Any effective hospital-wide security function must place a strong emphasis on the employment of adequate human and physical resources to protect the facility and people from suspicious, dangerous, or illegal activities� The Security Coordinator should develop, implement, and monitor a comprehensive security management function� The security function must provide a variety of services focused on safeguarding and improving the physical security of patients, staff, and visitors while protecting the rights of individuals in accordance with

BOX 3.10 RESPONDING TO DEVICE-RELATED INCIDENTS

• Protect the device, including packaging material and related parts� • Document the equipment or device engineering and/or serial numbers� • Remove the equipment from use and tag as defective� • Notify the patient’s physician as appropriate� • Notify Safety, Risk Management, and the appropriate response department� • Complete an incident report as required by the policies but within 24 hours� • The facility must file the report with the manufacturer or the FDA within 10 days�

all applicable laws� Security personnel must conduct regular patrolling of hospital campus and buildings� They should maintain a close liaison with local law enforcement officials and report/ investigate any suspicious or criminal activity� The security function must also conduct traffic control during emergency operations plan implementation and during normal operations of the hospital� An important objective involves controlling patient and visitor access to the emergency department and other hospital areas� The security function must also serve as goodwill ambassadors by providing assistance to employees and visitors with problems such as dead batteries or lost children� Security must report and assess all potential security concerns and identify incidents and issues for investigation and follow-up�

Chapter 13 of NFPA 99-2012 addresses security issues in emergency departments, pediatric locations, infant care units, medication storage locations, clinical labs, forensic patient treatment areas, and behavioral units� The chapter also addresses communications, data infrastructure, security of medical/health records, media relations, crowd control, employee practices, and security operations� Facilities must conduct a Security Vulnerability Analysis and plan for protection of people and resources beyond a disaster event� Security education should address customer relations, emergency procedures, use of force issues, importance of effective de-escalation of tense tactics, and restraint usage� The new code requires development of policies, plans, and procedures to address hostage situations, bomb threats, workplace violence, disorderly conduct, and restraining order policies�

The hospital must allocate and dedicate adequate physical and human resources to provide a reasonable level of protection from illegal acts� These physical resources could include two-way radio monitoring stations and security personnel� Silent “panic” alarms located in the emergency department can provide for faster response� The issuance of identification cards for employees, volunteers, physicians, ministers, and others requiring access can greatly improve security� Human resources can improve security by ensuring sufficient staffing of security personnel during overnight shifts and at times when there are other security-related concerns�

Leaders must require that all hospital employees report all suspicious individuals and activities to the appropriate security function or office for dispatch of security response personnel� Maintain accurate logs for all calls and dispatches� Ensure a management review of all security incident reports is completed by response personnel� Submit these reports to the Chief or Coordinator of Security Management� Report any incident resulting in injury to an individual, any assault on a hospital patient (whether an injury results or not), and any incident involving the brandishing or use of a weapon immediately to security and hospital leadership or a nurse supervisor� Analyzing all reports and providing appropriate information to the safety and/or risk management committees is recommended� The appropriate committee would then present a summary report of security issues to the governing board at least on an annual basis� Provide an evaluation of the objectives, scope, performance, and effectiveness of the Security Plan to the care environment director and/or committee on an annual basis�

Part of the security function involves safeguarding hospital and individuals’ property� Encourage patients to send valuables and other personal property home� Patients receive written information about safeguarding their belongings upon admission� Require hospital employees to report any theft

of which they become aware, and any individual carrying objects or packages that appear to belong to the hospital� Hospital security personnel may not conduct searches of patients’ and visitors’ persons or possessions� The hospital must investigate all thefts and other criminal acts reported� The organization should support the prosecution to the full extent of the law when a suspect is charged with a crime committed on hospital property�

The hospital must restrict and protect access to the facility including sensitive areas� All exterior doors, with the exception of the emergency department lobby and ambulance entrance doors, must be locked 24 hours or locked during certain hours in accordance with specific policy� Security personnel must make rounds to verify locked doors� Report unlocked doors and investigate as required� Security personnel must conduct periodic walk-through tours of construction areas unless the contractor employs construction site security officers� Sensitive areas should install additional controls such as fire stairwell alarms� Control patient flow in the emergency department through access (door) controls and intercom communication� Keep pharmacy doors locked at all times and limit the number of personnel with access� Locate medication rooms throughout the hospital in very visible areas near nursing stations and keep doors locked at all times�

The hospital must provide identification badges to all employees and volunteers� Outside contractors or vendors whose employees visit the hospital must use hospital-issued ID cards� Other vendors should report to materials management/purchasing prior to visiting other departments� Visitors who seek to enter the hospital after regular visiting hours must be screened by security� Provide for only one public entrance after 9 p�m� Suggest issuing color-coded visitor passes with the intended destination noted on it� Encourage all personnel to report any suspicious individuals seen on a hospital campus� Dispatch security personnel to question such individuals and escort them off hospital grounds�

The hospital must maintain designated traffic and parking controls� These controls include establishing fire lanes and crosswalks, posting speed limits, providing handicapped parking areas, and placing “no parking” signage in appropriate areas� The emergency department should provide a separate ambulance entrance and loading area� Security personnel must regularly patrol this area and other loading zones and fire lanes� When necessary, locate drivers leaving vehicles unattended and require them to move the vehicles�

Establish a firearms policy for the entire campus, including a policy for all security personnel� Security personnel authorized to carry a firearm must know the deadly force policy� The only occasion in which an officer should use a firearm is if he or she believes it is the only way that an individual can be stopped before using deadly force against another person� The hospital should define weapons as firearms (including air guns), knives (other than ordinary penknives and pocketknives), explosives, and any other deadly weapon as determined by the hospital� Publish policies and procedures for reporting and informing visitors, patients, and employees of this policy (noncompliant individuals will be asked by security to leave the hospital grounds)� Train security personnel to restrain violent individuals and do so upon request of nursing personnel/physicians or when, in their professional judgment, restraint is necessary to protect others�

Determine if security personnel can make arrests or must call local law enforcement authorities for assistance� Ban unwanted visitors and arrest violators for trespassing� Use additional security to seal off areas of the hospital such as the emergency department and screen anyone wishing to enter�

Plan to handle situations that might result in an influx of media representatives, a large patient entourage (e�g�, Secret Service personnel accompanying a federal officer), and/or large numbers of curious onlookers� Additional security personnel should be called in as needed by the administrator on duty� Contact local law enforcement authorities and/or use private security firms as needed�

Access control will depend in part on what area of the hospital that is affected� Officers can be stationed at each unlocked hospital entrance to screen visitors and issue incident-specific visitor passes� Plant operations personnel can be utilized to help set up physical barriers/controls as needed� Facilities not operating an isolated patient suite can limit access to certain areas/floors by way of guards� Hospital personnel can help detect and deter unauthorized attempts to gain access�

Consider using the hospital’s boardroom as a media work center� Facilities should provide a dedicated phone line cable in that area for such situations� An alternative site for media workspace is the cafeteria or a dining area� The hospital telephone system allows for blocking calls to specific patient rooms�

Security personnel and other identified staff members should undergo appropriate education and training to ensure they possess and maintain the skills and knowledge necessary to safeguard the security of patients, visitors, and staff� All hospital employees must receive instruction on security issues as part of their general orientation� This includes instruction on how to report security incidents involving patients, visitors, and employees, and how to summon security assistance� In addition, employees in security-sensitive areas of the hospital receive additional education in their departments to identify specific mechanisms or procedures designed to minimize security risk�

Security personnel must conduct ongoing assessments of security needs and issues� The safety and/ or care environment committees should establish performance standards and review effectiveness annually� The review should address the following areas:

• Staff security management knowledge and skill • Level of staff participation in security management activities • Security monitoring and inspection activities • Detailed security and incident reporting procedures communication • Inspection, preventive maintenance, and testing of security equipment

Hospital security professionals today better understand how to manage security risks than at any time in history� Increased and changing risks can compromise the effectiveness of security operations� OSHA workplace safety regulations and Joint Commission or other accreditation standards provide guidance on minimum requirements� Other organizations such as the American Society for Information Science (ASIS), the International Association for Healthcare Security and Safety (IAHSS), and NFPA also provide information on practices and guidelines that can help hospitals provide excellent security services� Learn from the successes-and mistakes-of other hospitals� Look for ways to improve security department capacity, reduce compensation expenses through better scheduling and management, and improve security officer recognition/performance�

Classify forensic patients into four categories: medical clearance, police hold, police custody, and emergency detention� The following four examples comprise the majority of forensic patients who interact with the general public every day in hospitals� Hospitals should run a risk assessment on police hold patients prior to intake� Hospitals must maintain responsibility for all patients and retain the right to ask how much of a danger a given patient presents to their facility� Healthcare security officers should continuously evaluate the status of forensic patients throughout their shift� All information on these patients should be passed on to relieving shifts� If possible, methods of tracking and flagging forensic prisoners should be integrated into the registration process� Nursing staff should report any concerns or suspicious activities involving their forensic patients�

NIOSH defines workplace violence as any physical assault, threatening behavior, or verbal abuse occurring in the workplace� Violence includes overt and covert behaviors ranging in aggressiveness from verbal harassment to murder� Nurses and nursing assistants suffer the most nonfatal assaults resulting in injury� BLS rates measure the number of events per 10,000 full-time workers-in this case, assaults resulting in injury� In 2000, health service workers overall had an incidence rate of 9�3 for injuries resulting from assaults and violent acts� Healthcare workers face an increased risk of work-related assaults stemming from several factors including handguns and weapons among patients, their families, or friends� Other risks include the following:

• The increasing use of hospitals by police and the criminal justice system for criminal holds and the care of acutely disturbed, violent individuals

• The increasing number of acute and chronic mentally ill patients released from hospitals without follow-up care

• The availability of drugs or money at hospitals, clinics, and pharmacies, making them likely robbery targets

• Factors such as the unrestricted movement of the public in clinics and hospitals and long waits in emergency or clinic areas that lead to client frustration over an inability to obtain needed services promptly

• The increasing presence of gang members, drug or alcohol abusers, trauma patients, or distraught family members

• Low staffing levels during times of increased activity such as mealtimes, visiting times, and when staff must transport patients

• Isolated work with clients during examinations or treatment

• Solo work, often in remote locations with no backup or way to get assistance, such as communication devices or alarm systems

• Lack of staff training in recognizing and managing escalating hostile and assaultive behavior

• Poorly lit parking areas

The healthcare sector leads all other industries with 45 percent of all nonfatal assaults against workers resulting in lost work days in the United States� From 1993 to 1999, approximately 765,000 assaults occurred against healthcare workers resulting in days away from work� From 2003 to 2009, eight registered nurses (RNs) were FATALLY injured at work� In 2009, there were 2050 assaults and violent acts reported by RNs, requiring an average of four days away from work� In 2009, the Emergency Nurses Association (ENA) reported that more than 50 percent of emergency center (EC) nurses had experienced violence by patients on the job and 25 percent of EC nurses had experienced 20 or more violent incidents in the past three years�

Lateral violence, also called “horizontal violence,” refers to acts that occur between workers and has been a long-term issue for nurses for decades, where nurses inflict psychological injury on each other� Horizontal violence, also called bullying, can be covert or overt acts of verbal and nonverbal aggression causing enough psychological distress to nurses to cause them to leave the profession� Rather than wait for healthcare employers to volunteer to establish such programs, some states have sought legislative solutions including mandatory establishment of a comprehensive prevention program for healthcare employers, as well as increased penalties for those convicted of an act of violence against a nurse�

1. Workplace Violence Protection for Nurses by Accrediting Bodies Although there is no federal standard that requires workplace violence protections, effective January 1, 2009, The Joint Commission on Accreditation of Healthcare Organization (JCAHO) created a new standard in the “Leadership” chapter that addresses disruptive and inappropriate behaviors in two of its elements of performance� First of all, there is an organization code of conduct that defines acceptable and disruptive and inappropriate behaviors� Secondly, leaders must create and implement a process for managing disruptive and inappropriate behaviors�

2. Workplace Violence Prevention (NIOSH Publication No. 2002-101) All hospitals should develop a comprehensive violence prevention plan� No universal strategy exists to prevent violence� The risk factors vary from hospital to hospital and from unit to unit� Hospitals should form multidisciplinary committees that include direct care staff as well as union representatives (if available) to identify risk factors in specific work scenarios and to develop strategies for reducing them� All hospital workers should be alert and cautious when interacting with patients and visitors� They should actively participate in safety training and be familiar with their employers’ policies, procedures, and materials on violence prevention� NIOSH defines workplace violence as “violent acts (including physical assaults and threats of assaults) directed toward persons at work or on duty�” This includes terrorism, as illustrated by the terrorist acts of September  11, 2001, which resulted in the deaths of 2886 workers in New York, Virginia, and Pennsylvania� Although these guidelines do not address terrorism specifically, this type of violence remains a threat to US workplaces� Healthcare and social service workers continue to face significant risk of job-related violence� Assaults represent a serious safety and health hazard within these industries� OSHA’s violence prevention guidelines provide recommendations for reducing workplace violence� OSHA suggests developing public and private violence prevention plans with input from stakeholders following a careful review of workplace violence studies and tracking their progress in reducing work-related assaults� Although not every incident can be prevented, many can, and the severity of injuries sustained by employees can be reduced� Adopting practical measures such as those outlined here can significantly reduce this serious threat to worker safety�

3. Management Commitment and Employee Involvement Management commitment and employee involvement remain the essential elements of effective safety and health plans� Management and frontline employees must work together using a team or committee approach� If employers opt for this strategy, they must be careful to comply with the applicable provisions of the National Labor Relations Act� Employee involvement and feedback enable workers to develop and express their own commitment to safety and health and provide useful information to design, implement, and evaluate the efforts� A worksite analysis involves a step-by-step, commonsense look at the workplace to find existing or potential hazards for workplace violence� This entails reviewing specific procedures or operations that contribute to hazards and specific areas where hazards may develop� A threat assessment team, patient assault team, or similar task force or coordinator may assess the vulnerability to workplace violence and determine the appropriate preventive actions to be taken� This group may also be responsible for implementing workplace violence prevention plans� The team should include representatives from senior leadership, risk management, security, safety and health, and human resources� The team or coordinator should periodically inspect the workplace and evaluate employee tasks to identify hazards, conditions, operations, and situations that could lead to violence� After identifying hazards through systematic worksite analysis, the next step is to design measures through engineering or administrative and work practices to prevent or control these hazards� If violence does occur, post-incident

BOX 3.11 WORKPLACE VIOLENCE PREVENTION

• Create and disseminate a clear policy of zero tolerance for workplace violence, verbal and nonverbal threats, and related actions� Ensure that managers, supervisors, coworkers, clients, patients and visitors know about this policy�

• Ensure that no employee who reports or experiences workplace violence faces reprisals�

• Encourage employees to promptly report incidents and suggest ways to reduce or eliminate risks� Require records of incidents to assess risk and measure progress�

• Outline a comprehensive plan for maintaining security in the workplace� This includes establishing a liaison with law enforcement representatives and others who can help identify ways to prevent and mitigate workplace violence�

• Assign responsibility and authority to individuals or teams while ensuring appropriate training and skill development� Make adequate resources so the team or responsible individuals can develop expertise on workplace violence prevention in healthcare and social services�

• Affirm management commitment to a worker-supportive environment that places as much importance on employee safety and health as on serving the patient or client�

• Set up a company briefing as part of the initial effort to address issues such as preserving safety, supporting affected employees, and facilitating recovery�

BOX 3.12 ELEMENTS OF VIOLENCE PREVENTION

• Management commitment and employee involvement • Worksite analysis • Hazard prevention and control • Safety and health training • Recordkeeping and evaluation

response can be an important tool in preventing future incidents� Engineering controls remove the hazard from the workplace or create a barrier between the worker and the hazard� Base the selection of any control measure on the hazards identified in the workplace� Administrative and work practice controls affect the way staff performs jobs or tasks� Changes in work practices and administrative procedures can help prevent violent incidents�

Post-incident response and evaluation can help prevent future violence� All workplace violence efforts should provide comprehensive treatment for employees victimized personally or traumatized by witnessing a workplace violence incident� Injured staff should receive prompt treatment and psychological evaluation whenever an assault takes place, regardless of its severity� Provide the injured transportation to medical care if not available onsite� Every employee should understand the concept of “universal precautions for violence”—that is, that violence should be expected but can be avoided or mitigated through preparation� Frequent training also can reduce the likelihood of being assaulted� Employees who may face safety and security hazards should receive formal instructions on the specific hazards associated with the unit or job and facility� This includes information on the types of injuries or problems identified in the facility and the methods to control the specific hazards� It also includes instructions to limit physical interventions in workplace altercations whenever possible� In addition, train all employees to behave compassionately toward coworkers when an incident occurs� Training and education should involve all employees, including supervisors and managers� New and reassigned employees should receive an initial orientation before being assigned their job duties� Visiting staff, such as physicians, should receive the same training as permanent staff� Qualified trainers should instruct at the comprehension level appropriate for the staff� Effective training should involve role-playing, simulations, and drills� Employees should receive required training annually� In large institutions, refresher education may be needed more frequently, perhaps monthly or quarterly, to effectively reach and inform all employees�

Supervisors and managers need to learn to recognize high-risk situations to ensure not placing employees in assignments that compromise their safety� They also need training to ensure that they encourage employees to report incidents� Supervisors and managers should learn how to reduce security hazards and ensure that employees receive appropriate training� Following training, supervisors and managers should be able to recognize a potentially hazardous situation and to make any necessary changes� Security personnel need specific training from the hospital or clinic, including the psychological components of handling aggressive and abusive clients, types of disorders, and ways to handle aggression and defuse hostile situations� Training sessions should also provide an opportunity for an evaluation� At least annually, the team or coordinator responsible for the plan should review its content, methods, and the frequency of training� Plan evaluation may involve supervisor and employee interviews, testing, and observing and reviewing reports of behavior of individuals in threatening situations�

The word ergonomics comes from the Greek words ergo, which means work, and nomos, which means law� It can also be referred to as the science or art of fitting the job to a worker� A mismatch between the physical requirements of a task and the physical capacity of the worker can result in musculoskeletal disorders� Ergonomics should focus on designing equipment and integrating work tasks to benefit the ability of the worker� Healthcare facility work environments expose patient and resident caregivers to ergonomic stressors� Successful ergonomic interventions must deal with personal issues instead of attempting to solve problems with universal solutions� Healthcare organizations should address ergonomic issues, risks, and injuries by developing a written ergonomics safety management plan� Ergonomic hazards refer to workplace conditions that pose the risk of injury to the musculoskeletal system of the worker� They include repetitive and forceful movements, vibration, temperature extremes, and awkward postures that arise from improper work methods and improperly designed workstations, tools, and equipment� Ergonomics addresses issues related to the “fit” between people

and their technological tools and environments� Ergonomics draws on many disciplines in its study of humans and their environments, including anthropometry, biomechanics, mechanical engineering, industrial engineering, industrial design, kinesiology, physiology and psychology�

Organizations should identify existing and potential ergonomics hazards� Assessment of work tasks must include an examination of duration, frequency, repetition, awkward postures, and magnitude of exposure to force in all lift tasks� Conduct environmental walk-through tours to ask workers about lifting or stressful tasks� OSHA logs and workers’ compensation injury reports can provide data related to ergonomic hazards� Use administrative controls to ensure adequate staffing� Emphasize the importance of patient or resident assessment to help determine level of risk for lifting, moving, or transferring tasks� Implement engineering controls to help isolate or remove the hazards by providing proper selection, training, and use of assist devices or equipment� Stress the early identification and treatment of injured employees� Develop a modified or transitional duty plan for workers recovering from an injury� Healthcare personnel experience a great variety of activities involving manual lifting, laterally transferring between two horizontal surfaces, ambulating, repositioning in beds or chairs, or manipulating extremities� Healthcare workers can also experience risks when transporting patients or equipment, performing activities related to daily living, stopping falls or transfers from the floor, and assisting in surgery�

Many organizations develop and implement an ergonomics policy with written goals, objectives, and accountability policies� Leaders should encourage worker involvement in ergonomics improvement efforts� NIOSH recommends reducing or eliminating potentially hazardous conditions by using engineering controls or implementing work practices and improved management policies� To meet ergonomics challenges, equipment should comply with ergonomics principles�

Effective training covers the problems found in each employee’s job� Training and education can go a long way toward increasing safety awareness among both managers and employees, and can keep employees informed about workplace hazards� Soliciting suggestions from workers about ergonomic hazards can help improve work practices� Effective training can ensure employees properly use equipment, tools, and machine controls� Reactive ergonomics only takes corrective actions when required to do so by injury or complaint� Proactive ergonomics seeks to identify all areas needing improvement� Attempt to solve problems by changing equipment design, modifying job tasks, and improving environmental designs� Healthcare providers need to be familiar with worker jobs and tasks and participate in matching jobs and work environments to worker needs� Use information obtained from job hazard analyses, job descriptions, photographs, and videotapes to identify ergonomic hazards� According to the International Ergonomics Association, physical ergonomics addresses human anatomical, anthropometric, and physiological issues that relate to physical activity� Cognitive ergonomics addresses the concern with mental processes such as perception, memory, reasoning, and motor response� Macro-ergonomics emphasizes a broad system view of design considering organizational environments, culture, history, and work goals� It deals with the physical design of tools and the environment� It is the study of the society and technology interface and considers human, technological, and environmental variables and their interactions�

BOX 3.13 EXAMPLES OF ERGONOMIC RISK FACTORS

• Jobs requiring identical motions every three to five seconds for more than two hours • Work postures such as kneeling, twisting, or squatting for more than two hours • Use of vibration or impact tools or equipment for more than a total of two hours • Lifting, lowering, or carrying more than 25 pounds more than once during a work

shift • Piece rate or machine-paced work for more than four hours at a time • Workers’ complaints of physical aches and pains related to their work assignments

Leaders should evaluate the effectiveness of ergonomics efforts and follow up on unresolved problems� Evaluation and follow-up are central to continuous improvement and long-term success� Good medical management can help eliminate or reduce development of ergonomic-related problems� The goal should be early identification, evaluation, and treatment of problems� Elements of medical management should include the following: (1) accurate reporting and recording, (2) responding to complaints and symptoms, (3) providing employee education, (4) conducting periodic surveys, (5) establishing baseline health assessments, and (6) implementing surveillance procedures�

Evaluations should assess prolonged work in any posture that may result in harm or injury� Assess offices, computer areas, and nursing stations� Evaluate force, duration, position, frequency, and metabolic expenditure of workers� Workers should be provided with good chairs that have arm and leg rests if required� Provide workstations that permit posture variations and have sufficient space for knees and feet� Workers such as admission personnel, appointment clerks, transcriptionists, medical coding personnel, and other data entry personnel that work on computers four hours or more each are at risk for developing hand, arm, shoulder, neck, or back disorders�

Signs of problems can include complaints of pain, tingling, numbness, swelling, and other discomforts� Employers should analyze trends, absenteeism, and turnover rates for those involved in data entry tasks� Workers should take short breaks often to allow the eye muscles to relax� Teach workers to glance at an object about 20 feet away� Some workers get relief by blinking or shutting their eyes for just a few seconds� Other interventions include padded keyboards, adjustable tables, and tilting screens� Allow workers to experiment to find a position that is comfortable to them� Ensure lighting is sufficient to help prevent glare and eyestrain� Provide glare control devices if necessary� Data entry personnel should take two or three short breaks for every hour of continuous work� Consider chair height as correct when the sole of a person’s foot can rest on the floor or a footrest with the back of the knee slightly higher than the seat of the chair� Workers should arrange desk accessories to reduce twisting and turning� The body is most relaxed with arms loose, wrists straight, elbows close to the body, and neck and spine straight� Any standing workstation should have an anti-fatigue mat, work surface below the elbows, and a footrest so the worker can elevate one foot� A sitting station should have a surface at least 18 inches wide and rounded in the front� Chairs should allow unrestricted movement, be adjustable, and support the lower back�

Human factors as a science concerns understanding the properties of human capabilities� The application of this understanding to the design, development, and deployment of systems and services relates to human factors engineering� Human factors can include sets of human-specific physical, cognitive, or social properties� These human factor sets can interact in a critical or dangerous manner with technological systems, the human natural environment, or human organizations� Human factors engineering applies knowledge about human capabilities and limitations to the design of products, processes, systems, and work environments� It also relates to the design of all systems having any type of human interface� Its application to system design improves ease of use and performance while reducing errors, operator stress, training, user fatigue, and product liability� It is the only discipline that relates humans to technology� Human factors engineering focuses on how people interact with tasks, machines or computers, and the environment with the consideration that humans have limitations and capabilities�

Changes in healthcare during recent years resulted in increasingly heavy demands on nurses and other healthcare workers� Extended schedules along with increased physical and psychological demands can increase the risk of experiencing musculoskeletal disorders (MSDs) and injuries� Healthcare workers experience more upper extremity workers’ compensation claims than workers in other industries� Nursing staff levels can impact physical and postural risk factors related to impaired sleep, pain medication use, and absenteeism� Encourage nurses to participate in ergonomics interventions� Traditional methods used to prevent work-related musculoskeletal injuries associated with patient moving include use of proper body mechanics, training personnel about safe lifting techniques, and the use of lumbar support belts� Evidence suggests that these three interventions, by themselves, prevent worker injuries� Many healthcare organizations now follow evidencebased practices such as providing patient handling equipment, implementing no-lift policies, and creating patient lift teams�

Early indications of MSDs can include persistent pain, restriction of joint movement, or soft tissue swelling� Activities outside of the workplace that involve substantial physical demands may also cause or contribute to MSDs� In addition, development of MSDs may be related to genetic causes, gender, age, and other factors� There is evidence that reports of MSDs may be linked to certain factors such as job dissatisfaction, monotonous work, and limited job control� Encourage workers to participate in the design of work, equipment, procedures, and training� Evaluate equipment regularly and respond to employee surveys� Effective solutions usually involve workplace modifications that eliminate hazards and improve the work environment� Work-related MSDs should be managed in the same manner and under the same process as any other occupational injury or illness� Like many injuries and illnesses, employers and employees can benefit from early reporting of MSDs� Early diagnosis and intervention, including return to duty procedures, can improve the effectiveness of employee treatment� Return to duty procedures can also minimize the likelihood of disability and reduce workers’ compensation costs�

Conduct a review that evaluates if the equipment is appropriate for the specific lifting or moving activity� The review should involve onsite testing of a variety of equipment by the end users� Provide for the convenient storage of assist and institutional equipment� This can ensure that equipment is easy to find and, in turn, help encourage healthcare workers to use it� Use flexible purchasing procedures that allow for the evaluation and purchase of up-to-date equipment with the most appropriate features� Administrative issues affect the equipment available to employees, the types of work tasks they perform, and the methods of accomplishment�

BOX 3.14 FACTORS IMPAIRING HUMAN PERFORMANCE

• Limited short-term memory • Running late or being in a hurry • Inability to multitask • Interruption of the job or task • Stress or lack of sleep • Fatigue or effects of shift work • Environmental factors • Personal or home distractions • Drug and substance abuse

A regular maintenance plan can help ensure sufficient quantities of equipment in all units or floors and avoid shortages and breakdowns� Some maintenance-related problems include jammed or worn wheels, which make it harder to move and steer or which cause chairs or other equipment to shift during transfers� Hard-to-reach controls or manual cranks on beds, chairs, or equipment can create risks and cause workers to assume awkward postures or make forceful exertions� Handles on beds, carts, or other equipment of the wrong size or placed at an inappropriate height can also contribute to injuries� Missing attachable IV/med poles can lead to workers awkwardly pushing gurneys or wheelchairs with one hand and holding free-standing poles with the other hand� Older mechanical lift devices can become hard to operate, uncomfortable, unstable, or even dangerous� High or heavy medical, food, or linen carts can result in unnecessary bending, reaching, or twisting when loading or unloading� Use systematic preventative maintenance techniques to keep all assist and moving equipment in proper working condition�

Healthcare workers may need to assume awkward postures because rooms, bathrooms, hallways, and other spaces are small, crowded, or contain obstructions� These factors may also prevent getting help from other employees or using assist equipment� Poorly maintained floors can cause slipping, tripping, and abrupt movements when lifting or moving patients, residents, or equipment� Welldesigned and maintained institutional equipment and facilities remain important factors in reducing or preventing back injuries� Institutional equipment should allow the user to maintain neutral body postures and reduce forceful motions� Beds, wheelchairs, cardiac chairs, and other equipment must be easy to adjust and move� Facilities should provide easy to operate equipment�

Train personnel on lifting equipment and proper procedures before permitting use of mechanical lifting devices� Always explain the lift to the resident or patient before beginning the procedure� Ensure the resident or patient is positioned correctly in the sling before continuing the lift procedure� One person must ensure that the patient remains stable during the entire lifting procedure� Never allow the sling to swing and never leave a patient or resident suspended in the sling� Mechanical assist devices or lifts can help reduce injury by avoiding unnecessary manual transfers, awkward postures, forceful exertions, and repetitive motions�

The first seven vertebrae, called cervical vertebrae, form the neck� Areas of the spine such as the neck, where flexible, can experience strains and sprains� The shoulder consists of a ball and socket joint where the ball of one bone fits into a hollow crevice of another� The shoulder joint allows movement and rotation of the arms inward, outward, forward, or backward� There are several different tendons attached to bones in the shoulder� Bursar reduces friction and cushions the tendons as they slide back and forth� The spine is a column of approximately 30 bones called vertebrae that run from the neck to the tailbone� These vertebrae stacked on top of one another in a shaped column form spinal joints, which move independently� Health spines contain three natural curves: a forward curve in the neck, a backward curve in the chest area, and another forward curve in the lower back� The back’s three natural curves should align correctly when ears, shoulders, and hips form a straight line� At the end of the spine, the vertebrae fuse together to form the sacrum and the tailbone� The lower back or lumbar area provides the workhorse capacity of the back� It carries most of the weight and load of the body� Aligning and supporting the lumbar curve properly helps prevent

injury to vertebrae, discs, and other parts of the spine� The spine contains various types of associated soft tissues like the spinal cord, nerves, discs, ligaments, muscles, and blood vessels� Discs, the soft shock-absorbing cushions located between vertebrae, allow these joints to move smoothly and absorb shock as you move� Each disc contains a spongy center and tough outer rings� The vertebrae are connected by a complex system of ligaments that knit them together� Strong flexible muscles maintain the three natural spinal curves and help in movement� The most important muscles that affect the spine include the stomach, hip flexors, hamstrings, buttocks, and back muscles�

A sprain refers to damage to ligament fibers caused by moving or twisting a joint beyond its normal range� A strain occurs when a muscle or a muscle tendon unit is overused� Bursitis is an irritation of bursa in the shoulder areas caused by rubbing on adjacent tendons� Tendinitis occurs when a tendon is overused and becomes inflamed� When the tendon sheath is involved, the condition is called tenosynovitis� Neck tension syndrome occurs where the last neck vertebra meets the first mudpack vertebra and is a major site of acute back pain, muscle tension, and other injuries� Common symptoms can include muscle tightness, soreness, restricted movement, headaches, and numbness/tingling in the hands, wrists, arms, or the upper back� Over time, discs wear out or degenerate from natural aging� The discs dry out and become stiffer and less elastic� The outer fibrous rings can crack and the discs narrow� They become less able to handle the loads put on them� If the inner jelly-like center bulges into the outer rings, it may compress nearby nerves or blood vessels� If the inner jelly-like center breaks through the outer rings, the condition is called a ruptured or herniated disc�

Common causes of back pain can relate to poor physical condition and being unaccustomed to a task� Other factors that contribute to pain include poor posture and lifting objects beyond a person’s ability� Contributing factors for back injuries include understaffing, inadequate training, poor body mechanics, inadequate safety precautions, and not using assist devices� The natural curves of the

BOX 3.15 COMMON ERGONOMIC-RELATED DISORDERS

• Tenosynovitis: This malady results in the inflammation of the tendons and their sheaths� It often occurs at the wrist and is associated with extreme wrist movement from side to side�

• Trigger Finger: A condition caused by any finger being frequently flexed against resistance�

• Tendinitis: A condition where the muscle-tendon junction becomes inflamed due to repeated abduction of a body member away from the member to which it is attached�

• Tennis Elbow: This form of tendinitis is an inflammatory reaction of tissues in the elbow region caused by palm upward hand motion against resistance, such as the violent upward extension of the wrist with the palm down�

• Carpal Tunnel Syndrome: A common affliction caused by the compression of the median nerve in the carpal tunnel� It is often characterized by tingling, pain, or numbness in the thumb and first three fingers� It is often associated with repeated wrist flexion�

• Reynaud’s Syndrome: A condition where the blood vessels in the hand constrict from cold temperature, vibration, emotion, or unknown causes� It is easily confused with the one-sided numbness of carpal tunnel syndrome�

spine are held in place and supported by muscles in the back and abdomen� These muscles must be strong and healthy� If standing for a prolonged period, one foot should rest on a low stool to support the lower back� Keep the head up and chest lifted� Select a chair that supports the lower back but is not too high� Tuck the buttocks and keep feet flat on the floor� Sleep on the back if possible with a small pillow under knees, or sleep on the side with knees bent� Never sleep on the stomach, or on the back with legs straight out� A fitness program that improves aerobic capacity while strengthening back muscles can help prevent back pain� Each individual should choose an exercise program that fits their needs and abilities� NIOSH has now concluded that the use of lumbar support belts to reduce the risk of injury remains unproven� NIOSH previously concluded that the lumbar supports do not reduce spinal compression during heavy lifting tasks� NIOSH also expressed concerns that the belts might give workers a false sense of security and result in some lifting excess weights� The NIOSH study only reviewed data from other studies and did not do any original research� Several recent scientific studies conducted at leading universities indicate that correctly fitted lumbar support belts could help alleviate pressure on the soft tissue of the back and spine� Some associations and insurance groups claim that the use of support belts has resulted in a significant reduction in workers’ compensation costs� Use back support belts only when included as an integral part of total back care management efforts�

The lower discs can experience more damage than other discs because they bear most of the load in lifting, bending, and twisting� Sciatica occurs when bulging or ruptured discs constrict the sciatic nerve of nearby blood vessels causing pain to the hips, buttocks, or legs� Degenerative or osteoarthritis simply means the wearing out of joints, vertebrae, discs, facets, or other structures over time� Osteoarthritis is associated with loads put on the spine over long time periods� As the discs dry out and narrow, they lose their shock-absorbing ability� The vertebrae become closer together, irritated, and may produce bony outgrowths� Facet joint syndrome occurs when the facets interlock with the vertebrae above and below to form joints in the spine� The facets can become misaligned from bending, lifting, and twisting while working� Slipped vertebrae occur when the vertebrae in the lower back pushes forward so they don’t line up with other vertebrae� This condition disrupts the proper natural curves of the spine and causes joints, ligaments, and muscles to become overburdened� Spinal canal narrowing can occur in the canal that the spinal cord runs through or in the gap at the sides of vertebrae where nerves exit�

Management and prevention efforts should focus on eliminating lifts wherever possible� Use patient handling, transfer, and lifting equipment� Establish patient lift guidelines to help workers safely assess patient handling situations� Redesign the workplace to increase efficiency and decrease the potential for injuries� Educate workers about back anatomy and personal back care responsibilities� Provide recurring education and training on proper body mechanics and patient transfer techniques� Require employees to participate in exercise and/or stretching routines before lifting� Establish and train two-person lift and transfer teams� Use physical or occupational therapy professionals to instruct workers in patient handling techniques� Assess the patient or resident before lifting or moving them� Eliminate or reduce manual lifting and moving of patients or residents whenever possible� Get patients or residents to help as much as possible by giving them clear, simple instructions with adequate time for response� Know your own limits, do not exceed them, and get help whenever possible� Never transfer patients when off-balance� Never permit workers to lift alone� Require team lifting for fallen patients and when using assistive devices� Limit the number of allowed lifts per worker per day� Investigate all accidents and make changes to prevent recurrence� Assign a case management worker to oversee medical treatment and return to work efforts� Never move or lift from side to side� Plan the lift and size up the load to better reduce spine movement� Keep the patient load as close to the body as possible� Ten pounds at waist height equates to 100 pounds force on the back with arms extended away from the body� Bend at the knees when lifting loads from floor level�

Ten pounds at floor height with bent knees is equal to 100 pounds of force when bending at the waist with legs straight� Avoid any twisting motion and pivot the feet to turn� Always push rather than pull loads� Pushing reduces the force necessary to move an object by 50 percent� Use lifting equipment and devices such as chair lifts, mechanical lifts, transfer boards, and gait belts� Keep beds at proper heights� Keep the back straight and maintain correct posture with head up and stomach tucked in�

1. Lateral Transfers Use lateral transfers or sliding techniques to move patients and residents between two horizontal surfaces such as bed to gurney� Helpful equipment and devices include slide boards, transfer mats, slippery sheets, draw sheets, and incontinence pads�

2. Ambulating, Repositioning, and Manipulating For help with these types of activities, use equipment and gait belts, transfer belts with handles, slippery sheets, plastic bags, draw sheets, incontinence pads, pivot discs, range of motion machines, fixtures, etc�

3. Performing Activities of Daily Living These activities include showering, bathing, toileting, dressing or undressing, and performing personal hygiene and related activities� Equipment devices include shower toilet combination chairs, extension hand tools, shower carts, gurneys, and pelvic lift devices�

4. Useful Tips Encourage healthcare workers to use assist equipment and devices� Some suggestions about assist devices and equipment follow:

• Purchase the proper devices in sufficient quantities • Store devices in areas visible and readily available • Involve end users in evaluating and selecting devices • Ensure the organization accomplishes effective training on device usage • Equip devices with sufficient replacement accessories such as slings • Implement a comprehensive maintenance plan for all devices

5. Lift Teams Some organizations choose to create a special “lift team” dedicated to performing the majority of the lifting or moving of patients or residents� The lift team should coordinate with the nurses and other medical personnel responsible for the patient or resident� Some organizations train teams to

• Eliminate uncoordinated lifts • Prevent unprotected personnel from performing lifts

BOX 3.16 BACK INJURY PREVENTION TIPS

• Educate nurses on proper back care and use of proper body mechanics • Provide recurring training on patient transfer techniques • Implement exercise routines for those involved in lifting • Establish, educate, and train lifting teams • Conduct periodic ergonomic evaluations to detect problem areas • Ensure implementation of effective housekeeping procedures • Acquire and require the use of patient lift and assist devices and equipment

• Reduce weight and height differences between partners • Prevent untrained personnel from lifting • Encourage the use of lifting equipment when possible

6. Guiding and Slowing Falls Review patient or resident assessments and watch for signs of weakness� If falls do occur, attempt to guide, slow, and lower the patient or resident to the floor� Try to maintain a neutral body posture when assisting patients� Regulatory reporting requirements may cause employees to try stopping a fall� Reporting of falls should not lead to fault-finding or negative consequences�

7. Transfer Task Safety Communicate the plan of action to the patient and other workers to ensure that the transfer takes place using smooth techniques that consider unexpected moves by the patient� Remove any obstacles and focus on maintaining sure footing� Patients should wear slippers that provide good traction� Maintain eye contact, communicate with the patient, and stay alert for trouble signs� Record any problems on the patient’s chart so that other shifts will know how to cope with difficult transfers� Also note the need for any special equipment� Implement measures to reduce or prevent back injuries such as

• Developing a return to work or modified duty procedure • Writing job descriptions that establish the appropriate physical requirements • Requiring immediate reporting and treatment of injuries

8. Personal Factors Home and recreational activities involving forceful exertions or awkward postures can also lead to or aggravate back injuries� Some examples include sports and home repair work� Physical fitness, weight, diet, exercise, personal habits, and lifestyle may also affect the development of back injuries� Individuals not in good physical condition tend to have more injuries� Excessive body weight can place added stress on the spine and is often associated with a higher rate of back injuries�

Previous trauma or certain medical conditions involving bones, joints, muscles, tendons, nerves, and blood vessels can also contribute to back-related disorders� Psychological factors, such as stress, may influence the reporting of injuries, pain thresholds, and even the speed or degree of healing� Physically fit individuals tend to have fewer and less severe injuries� Remember to consult with a physician or physical therapist about which aerobic, strength, and flexibility exercises to do� This is especially important for those individuals who have preexisting injuries or medical conditions�

9. Work Evaluation Tools Involve the employees performing the work in evaluating problems and coming up with potential solutions� Following the simple three-step hazard control process can help reduce lifting-related injuries and complaints� The first step in the process is to identify lifting tasks by observing and evaluating patient/resident needs on the unit� The second step involves analyzing both data and observations� Conduct observations for a period of time to validate the actual tasks� The analysis step should help managers identify causal factors related to lifting or moving tasks� Once the analysis step is completed, the identification and assessment team can consider appropriate control to reduce worker risk of injury� Never select and implement controls if accomplishing the identification and analysis steps incorrectly�

Provide training at the level of understanding appropriate for those being trained� Give workers an opportunity to ask questions� Provide an overview of the potential risks, causes, and symptoms of back injury and other injuries� Teach workers how to identify existing ergonomic stressors

and methods of control� Explain the use of engineering, administrative, and work practice controls needed to conduct patient or resident handling tasks� Encourage workers and staff to stay physically fit� Provide education and hands-on practice that allows feedback� Review the work task analysis and evaluation information� Implementing improvement options or controls should guide the type of education provided� Training and education must focus on the nature and causal factors of worker injuries� Require that employees demonstrate the skills learned in a competency evaluation� Provide a systematic approach reinforced by retraining� Training is usually most effective when it includes case studies or demonstrations� Answer any questions that may arise during the training� Ensure that charge nurses and supervisors participate in the education and training� They should reinforce safety policies and oversee incident reporting requirements� Supervisors should ensure the implementation of task-specific procedures and adherence by workers to published policies�

Some hospitals transport patients using members of a trained team� Theses transporters move patients to various locations in the hospital complex� Patient transportation may involve high-risk patients, such as patients using an oxygen tank� Some transport team members also collect and deliver laboratory specimens� Transporters may transport equipment such as stretchers and wheelchairs� Transporting patients from one location to another includes vehicle to bed, room to procedure area, or building to building� Patient transporters serve as the frontline custodians of patient experience� The patient transportation staff must receive thorough training in all aspects of safe patient handling procedures including lifting protocols and infection control� Transportation functions must stress prompt and efficient services� Patient transport services require strong leadership� Effective transportation services permit nurses and staff members to focus on patient care requirements�

Establish practices to ensure safe care during the transport of patients� Transporters must learn to recognize hazards during the transport journey� Consider the following issues when planning for a transport: (1) need for IV poles, (2) need for transport oxygen tank, (3) conscious state of patient, and (4) the age and size of patient� Determine physical abilities and the condition of the patient� Consider the following when selecting the type of transportation to use:

• Wheel-locking capability and need for safety straps • Side rail height sufficiency to prevent falls • Need to transfer IV poles • Ability to accommodate patient positioning • Mattress on gurney is held in place • Ability to use patient transfer device • Maneuverability of transportation device • Transportation device deemed safe

The individual who is transporting the patient should introduce and identify herself/himself to lessen patient anxiety� Correctly identify the patient to prevent wrong-patient surgery� If the patient is conscious, explain the transfer procedure prior to implementation to reduce the anxiety of the patient and promote safety� Maintain the patient’s dignity during the transfer� This will aid in decreasing the patient’s anxiety and ensure personal and moral rights� Adhere to all safety procedures, including the following:

• Elevate the side rails and apply a safety strap • Confirm IV lines, indwelling catheters, monitoring lines, and drains • Protect head and arms and make the patient as comfortable as possible • Transport patient feet first and avoid quick movements • Verbalize to patient to keep hands and arms inside the safety rails • Explain all actions to conscious patient • Maintain dignity by keeping the patient covered at all times

Interdisciplinary transport teams can help to reduce patient risk during transport by using standardized protocols and policies� Transport team policies should include the use of sound communication techniques and teamwork with specific roles and responsibilities� The facility must obtain the appropriate equipment to ensure safety� Ensure the curriculum for transport team members focuses on ensuring competency� Education should include lessons on intravenous lines, catheters, and oxygen use� It should also include CPR certification, knowledge of patient safety goals, and handoff communication procedures� Organizations must develop standardized handoff communication checklists to ensure patient safety� Transport teams can help patient safety efforts and reduce the potential for adverse events� Develop a transport team model of care with a clear outline of the specific responsibilities for each team member� Coordinate pre-transport communication between the transporter, nurse, and the destination location� Ensure that patient equipment is functional, fully charged, filled, and in good repair�

BOX 3.18 QUESTIONS RELATED TO TRANSPORT PERSONNEL

• Do unlicensed and licensed personnel transport patients? • What are their specific responsibilities before and during transport? • What are the competency assessments necessary to ensure patient safety during

transport? • What should minimum basic life support training entail for transport personnel? • Does training cover how to receive and provide handoff communications?