🚑"Don't Fall for it"
Using this ensures all post-fall documentation is complete and thorough.
What is the Post-Fall Documentation tab in Flowsheets?
This stage presents as non-blanchable redness over a bony prominence.
What is Stage 1 pressure injury?
This is the MOST effective way to prevent healthcare-associated infections.
What is hand hygiene?
Second-nurse verification is needed for this type of high-risk PINCH medication.
What are Heparin infusions, when confirming a heparin assay or PTT?
During an emergency, call this number to report a code.
What is 2-1212?
These are the two most important immediate nursing actions after a patient fall is discovered.
What are assess the patient and call for help?
This must be done within 8 hours of an admission to identify skin concerns.
What is the 4-Eyes Skin Assessment?
This should be performed daily for all patient with a foley catheter, to reduce risk of developing a CAUTI.
What is Foley care/Peri care?
Before starting a heparin infusion, this baseline lab is critical to assess bleeding risk.
What is platelet count (and/or baseline aPTT)?
Other than documentation completed in Epic, this should also be completed after a code.
What is a Stars Safety Report?
A patient tries to get up without calling despite education—this intervention is often the most effective next step.
What is implementing a bed alarm?
This should be done every shift for every patient to identify skin concerns early.
What is a full skin assessment?
This should be evaluated daily with the team for all patients with a central line.
What is line necessity?
This cardiac change is commonly seen with hyperkalemia.
What are peaked T waves?
These two actions can be done at the beginning of the code to ensure no delay in intubation.
What is pull out the bed and place the airway roll at the head of the bed?
Other than documentation in a patient's chart, this also needs to be completed for all falls.
What is a Stars Safety Report?
For any patient with a Braden Score <18, we should be documenting our prevention interventions here.
What is the "Equipment and Supportive Therapies" section in the Daily Cares flowsheet?
This is the recommended action if a central line dressing becomes damp, loose, or visibly soiled.
What is change the dressing immediately using sterile technique?
A respiratory rate below this number should prompt you to HOLD an opioid.
What is less than 12?
For a patient in a shockable rhythm like ventricular fibrillation or pulseless ventricular tachycardia, defibrillation should occur within this time frame.
What is as soon as possible (ideally within 2 minutes of recognition)?
This is the MOST common time frame when inpatient falls occur.
What is during toileting or overnight hours?
This MUST be documented in the flowsheet to support pressure injury prevention compliance.
What are specific changes in patient positioning q2h?
What 3 things need to be changed every 96 hours (or as needed) to prevent line infections?
What are IV tubing, IV fluid bags, and needle-free end connectors?
This is the MOST common cause of medication errors.
What is interruption/distraction during med administration?
These four elements are required for high-quality CPR per ACLS guidelines.
What are adequate rate (100–120), adequate depth (at least 2 inches), full chest recoil, and minimal interruptions?