Fall Safe
Call bell within reach, fall script, bed alarms on, yellow socks , yellow arm band and care plan
What is the fall bundle?
Name and date of birth
What are the 2 identifiers?
30 minutes
What is the time frame for the transfusion to be initialed after release from the blood bank?
Maximum duration for a non violent restraint order
What is one day?
Call bells, sheets, curtains, BP equipment , O2 tubing
What are ligature risks?
Done on admission, transfer and post fall
What is the Morse fall score?
MS, qd, od, trailing zero
What are unapproved abbreviations?
Matching the blood component to the order and matching the blood component to the patient using 2 identifiers
What are components of meeting the NPSG's goal of eliminating transfusion errors?
Level of orientation, respiratory status, correct application of restraints, signs of injury, readiness for removal, circulation in the extremities
What is the nursing assessment?
Constant Observation and environmental safety precautions
What are suicide precautions?
Age, bones, coagulation and recent surgery
What are risk factors for increased injury from a fall?
CLABSI and CAUTI Bundles
What are strategies to prevent Health Care Associated Infections?
Return to the blood bank
What should be done if the blood cannot be transfused within 4 hours?
Done every 2 hours
What is comfort care?
Age, bones, coagulation, post surgery
What is ABCS?
Assess the patient, do VS, call provider and NM, and conduct post fall huddle
What are components of post fall management?
In the presence of the patient at the bedside
Where should specimens be labeled?
Prior to the start, 15 minutes after initiation, then hourly and 15 minutes after completion
How often should vital signs be done?
Severe agitation,interference with medical devices, elopement risk and high risk for falls
What are indications for safety observation?
Standard Work to Achieve Relationship Centered Care
What is STAR?
Pain, position, proactive toileting and possessions?
What is purposeful hourly rounding?
Site marking and time out
What are components of the universal protocol?
Stop the blood, assess patient, and return remaining blood and tubing if transfusion will not be continued
What should you do if the patient is experiencing signs of a transfusion reaction?
Completed by RN every 8 hours
What is Safety Observation Risk Assessment algorithm?
Admission welcome, bedside shift report. AM/PM care, 5 minute sit down, medication review, Discharge wrap up
What is Relationship Centered Care?