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?
The time frame for the transfusion to be started after release from the blood bank
What is 30 minutes ?
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?
A signed consent is required for the administration of blood products, including red blood cells, platelets and plasma and it is valid for
What is the duration of the patient’s hospitalization?
Level of orientation, respiratory status, correct application of restraints, signs of injury, readiness for removal, circulation in the extremities
What is the restraint 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?
You are unable to transfuse the blood within 4 hours
What is return to the blood bank?
Done every 2 hours while patient is restrained
What is comfort care?
Age, bones, coagulation, post surgery
What is ABCS?
Assess the patient, assess vital signs, call provider and NM, document in EPIC, and conduct post fall huddle
What are components of post fall management?
Specimen should be labeled
What is in the presence of the patient and at the bedside?
The vitals should be done...
What is prior to the start (no more than 30min prior), 15 minutes after initiation, hourly and 30 minutes after completion
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 at patient bedside and immediately before starting procedure
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?