Safety in the Rehabilitation Setting: A Nursing Perspective




Patient safety, including keeping patients safe from harm or unintentional injury, is key to shortening the length of hospital stays, encouraging positive patient outcomes, and contributing to the hospital’s financial state. Freedom from pressure ulcers, falls, and medication errors is an important component of patient safety. The parallel concept of nurse safety cannot be ignored. Keeping nurses safe from injury helps decrease their feelings of stress and minimizes sick time. Maintaining a safe environment for patients and staff is a win–win situation for all involved.


Overview of patient safety


It is a new era for rehabilitation centers. Patients admitted have significant comorbidities. Insurance companies are denying appropriate patients admission to the rehabilitation center. It is becoming increasingly difficult to maintain occupancy. Administration is watching their bottom line and the contribution of rehabilitation to margin. Governmental regulations threaten the survival of rehabilitation centers. These factors together result in fiercer competition for patients among rehabilitation centers.


Patients and families, as consumers, have many tools at their disposal to help them choose a rehabilitation center. The public can access www.hospitalcompare.hhs.gov to see how well an institution is doing in terms of patient satisfaction scores and safety. They want facilities that have physiatrists with great reputations, appropriate nurse/patient ratios, and a place that has excellent patient outcomes in function and safety. As a consequence, there is now increased attention and emphasis on patient safety.


Safe patient care is also vital to an institution’s financial well-being. A decreased incidence of patient falls, pressure ulcers, medication errors, and wrong-site surgery means a shorter patient length of stay. This translates into increased revenue for the institution (hospitals receive monies per patient discharge).


Definitions of Safety


According to the Oxford Dictionary safety is defined as “the condition of being protected from or unlikely to cause danger, risk, or injury.” “The prevention of harm to patients” is how the Institute of Medicine defines patient safety.


The Joint Commission standards outline general guidelines for safety in describing the appropriate environment of care. Elements include the actual building or space for patients, visitors, and staff; the equipment used to support patients and maintain the building or space; and all people who enter the environment. Table 1 outlines the general categories related to patient safety and some examples of risk prevention.



Table 1

Joint Commission general categories related to patient safety




























Aspects of the Environment Description Examples of Risk Prevention
Safety and security Physical environment, access to security-sensitive areas, smoking, product recalls Appropriate security measures, prohibition of smoking with policy
Hazardous materials and waste Chemicals, radioactive materials, hazardous energy sources, hazardous medications, hazardous gases, hazardous vapors Inventory of hazardous items, proper labeling of hazardous materials, choice of safe equipment
Fire safety Fire, smoke, other products of combustion, fire response plans, fire drills, management of fire detection, alarms and suppression equipment and systems, measures to implement during construction or when life safety code cannot be met Free and unobstructed exits, fire response plan, fire drills at least once per shift per quarter in each building with documentation, monthly inspection of fire extinguishers with documentation
Medical equipment Selection, testing, maintenance of medical equipment and contingencies when failure occurs End user participation in choice of equipment, plan for inspecting, testing, and maintaining equipment, reporting and analysis of failures
Utilities Inspection and testing of operating components, control of airborne contaminants, management of disruptions Availability of emergency power, testing and management of medical gas systems


Other Joint Commission safety topics include a detailed description of life safety standards as described in the National Fire Protection Association Life Safety Code. The life safety chapter lists specific criteria for the physical environment, protection during construction or when the Life Safety Code is not met, building and fire protection features integrity of means of egress, the maintenance of fire alarm systems, systems for extinguishing fires, and other very specific requirements.


The Joint Commission introduced the National Patient Safety Goals program in 2002 with the goal of assisting organizations to focus on important areas of patient safety. The goals are continuously evaluated so that they may represent current best practices. For example, elements for attainment of the goals are reexamined and may be revised to pinpoint specific risk areas. Goals may also be dropped from the safety goal list and added to elements of overall standards. A goal for implementation in 2012 addresses catheter-associated urinary tract infection (CAUTI). This particular goal is extremely relevant to rehabilitation nursing as a nurse-sensitive indicator. In one staff nurse–initiated study on rehabilitation units, ownership of the process of prevention by nurses was described as the major factor in decreasing CAUTI.


The other National Patient Safety Goals are also closely related to the work of rehabilitation nurses, including patient identification, effective communication, safety in medication administration, reducing the risk of health care–associated infections, medication reconciliation, and the universal protocol.


Suicide prevention has been recognized as another goal for healthcare settings, including the rehabilitation patient population. In a recent retrospective cohort study, the authors evaluated the mortality, life expectancy, risk factors for death, and causes of death after traumatic brain surgery rehabilitation. They identified that persons experiencing traumatic brain surgery are three times more likely to commit suicide than persons in the general population.


In 2010, the Joint Commission issued a sentinel event alert related to the prevention of suicide in nonpsychiatric settings. The focus of the alert was to urge staff in nonpsychiatric settings to screen for suicidal risk. The Joint Commission alert highlighted the fact that suicide ranks in the top five events reported to the Joint Commission and that 2.45% occurred in nonpsychiatric settings, such as “home care, critical access hospitals, long term care hospitals and physical rehabilitation hospitals.” Among the risk factors described in the alert were “physical health problems, including central nervous system disorders such as traumatic brain injury, chronic pain or intense acute pain; poor prognosis…disability.” The Joint Commission alert urged all facilities to consider what additional risk reduction strategies are appropriate for their particular setting.


The National Quality Forum Update identified 34 safety practices for healthcare organizations to adopt to improve patient safety. The categories of practices include a culture of safety, communication, medication management, prevention of infections, and others. These standard safety practices can be used to guide rehabilitation settings in goals for safety improvement.


Rehabilitation nurses are primary stakeholders in the application of these Joint Commission and other quality standards for the rehabilitation setting. One commonly mentioned idea for the identification of safety issues is clinical safety rounds. In a randomized study of clinical safety rounds, a rounding intervention by hospital executives and others demonstrated improvement in the nurses’ perception of safety culture. Executive Walk Rounds was conducted by leadership staff trained in the method; staff reported safety concerns for follow-up. Campbell and Thompson described an application of clinical safety rounds in an academic medical center. Rounds centered on small groups of staff on individual hospital units. A standard approach was created and used by the rounding team. For example, specific questions were asked on rounds to stimulate discussion about safety and the identification of salient concerns and worries about patient safety. The data resulting from the rounds were analyzed and led to changes in general processes of care and the resolution of specific local problems.


Although nurses were involved in these two rounding initiatives, nurses were not identified as the primary leaders. It is possible that nurses conducting their own local safety rounds could provide additional information regarding their organization’s safety vulnerabilities. Nurse rounding on patients has been advocated as a patient satisfaction strategy with a safety component. The results of a quasiexperimental study suggested that hourly rounding on patients decreased falls and led to greater patient satisfaction. Rehabilitation nurses may be able to further elaborate processes and strategies for the identification of safety issues and interventions in the rehabilitation population.


Patient Safety Education and Competencies


The current emphasis on patient safety has stimulated an examination of nurse competencies related to patient safety. A national initiative called the Quality and Safety Education for Nurses adapted the competencies identified by the Institute of Medicine and formulated key nurse competencies, all of which relate to safety for the patient. For example, patient-centered involves developing an active partnership with patients and families. Teamwork and collaboration target the ability to effectively communicate with team members. Evidence-based practice focuses on need to use high-quality evidence for information. The safety competency emphasizes standardized practice, communication of hazards and errors, and reporting of near misses and risk events. Finally, the informatics competency values technology to effectively prevent errors and coordinate care. Although this initiative began as an academic endeavor and has also included clinical partnerships as described by Fater and Ready, these key competencies should be threaded through nurse orientation and clinical continuing education for rehabilitation nurses.


A review article evaluated patient safety assessment tools, including nine tools for nursing professionals. The nursing tools included the following: quality improvement knowledge, skills, and attitudes; patient safety attitudes, skills, and knowledge scale; essay; situation awareness checklist; clinical simulation evaluation tool; knowledge, skills attitudes criterion, clinical performance evaluation tool; and two unnamed checklists. Of these tools, only the quality improvement knowledge, skills, and attitudes and the patient safety attitudes, skills, and knowledge scale were reported to have content validity. Although it may not yet be practical to use these evaluation tools, other outcome measures already part of rehabilitation nursing can be the focus at this time, such as decreased falls, decreased pressure ulcers, and decreased infection, all of critical and practical importance to rehabilitation patients.


Patient Populations in Rehabilitation Centers


The patient population in rehabilitation units and centers are individuals who not only have a disability but who still require medical attention and 24-hour nursing monitoring and care. Consequently, discharge from the acute setting to home or a subacute facility is not a viable option. Common disabilities seen in the rehabilitation setting include brain injury (traumatic and nontraumatic); spinal cord injury (traumatic and nontraumatic); stroke; amputation; debility; and persons having undergone hip or knee replacement. By nature of these disabilities many patients have cognitive or memory deficits, problems with perception, gait disorders, swallowing difficulties, or other significant functional deficiencies. In addition, because of the push to shorten length of stays in acute hospitals, patients are entering rehabilitation centers with an increased number of comorbidities and are sicker than in previous years.


The goal of rehabilitation is for the person with a disability to increase their functional or cognitive level of independence and, when appropriate, how to direct their care. The patients attend therapy and are taught strategies to overcome physical, psychological, or cognitive deficits. In this nursing plays a large part. Nurses not only direct and advocate for the patient to practice what they have learned in therapy but are also instrumental in education of the patient and their family. Areas of educational focus include bowel and bladder management, skin care, respiratory function, and health promotion and wellness.


The combination of high acuity, physical and cognitive impairments, and emphasis on increasing independence mandates an increased awareness of safety issues by the rehabilitation nurse. The rehabilitation patient is at risk for falls, pressure ulcers, and aspiration pneumonia.


Elements of creating and maintaining a safe patient environment include effective communication; a sound education program (for patients and staff); and adequate staffing. Communicating at change of shift reports or at hand off before breaks informs one’s colleagues about patient status and potential problems. Being up to date on the latest technology or new medications not only helps improve the patient’s medical and functional status, but alerts the nurse to any potential errors in medication orders or inappropriate use of a product. Adequate staffing prevents staff fatigue, which can lead to poor judgment and decision making and ensure timely answering of the call bell. This prevents patients from putting themselves in harm’s way because they become impatient waiting for help and try to do for themselves.


The focus on patient safety is not a new issue or concern in health care. Keeping patients safe while in the hospital has always been the priority for nursing. This dates back to Florence Nightingale, who wrote “It may seem a strange principle to enunciate as the very first requirement in a hospital that it should do the sick no harm.”


Over the years, landmark studies by the Institute of Medicine, Agency for Healthcare Research and Quality, National Quality Form, Institute for Healthcare Improvement, and regulatory agencies, such as The Joint Commission and Centers for Medicaid and Medicare (CMS), have identified strategies to improve health care and keep patients safe.




Identification of top safety issues: problem and prevention strategies


Medication Safety


According to the Institute of Medicine, medication errors are among the most common medical errors. It is estimated that at least 1.5 million people are harmed every year as a result of a medication error. These medication errors result in extra medical costs of $3.5 billion a year to treat drug-related injuries. Efforts to decrease the number of medication errors consist of increased communication and education. Consumer-friendly pamphlets highlighting and outlining medication routes, purpose, and side effects should be made and given to patients. These pamphlets should be written in a way that patients understand what is being communicated. The standard is for the information to be written at the fourth grade level. In addition, pamphlets in other languages, those that are prevalent in one’s area, should be readily available.


All nurses know about the five rights of medication administration. However, most do not know that some experts advocate eight rights of medication ( Table 2 ).



Table 2

The five rights of medication administration











































Number Right Components
Known five rights 1 Right patient Use two identifiers
2 Right medication Check medication label
3 Right dose Check order
4 Right route Check order and appropriateness of route
5 Right time Check frequency of ordered medication and time of last dose
Lesser known rights 6 Right documentation Document after medication is given
Chart all pertinent information including time, dose, route, response
7 Right reason Confirm rationale for medication
8 Right response Was desired response achieved?
Document response


Pressure Ulcers


There have been many estimates made of pressure ulcer–related costs. A CMS estimate in 2007 placed the average cost of preventable pressure ulcers at $43,180 per hospital stay. Another estimate placed pressure ulcer–related costs between $5 and $8.5 billion annually, with per patient costs estimated at more than $10,500 per patient. Length of stay is increased for patients with pressure ulcers (30.4 vs 12.8 days), with subsequent increases in cost.


The incidence of pressure ulcers in hospitalized patients in the United States is reported to range from 1.5% to 10.3%. A consensus paper from the International Expert Wound Care advisory panel also reported pressure ulcer incidence in this range, with incidence of new pressure ulcers in acute-care patients approximately 7%, with wide variation among institutions. CMS reported 257,412 cases of preventable pressure ulcers as secondary diagnoses in 2007.


The National Pressure Ulcer Advisory Panel defines a pressure ulcer as “localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction” ( npuap.org/pr2.htm ). This panel defines six classifications of pressure ulcer, stages I-V, suspected deep tissue injury, and unstageable ulcers.


A number of conditions place individuals at risk for the development of pressure ulcers. These risk factors include prolonged immobility; friction (rubbing); shearing; decreased sensation to the area or decreased cognition; excessive moisture or dryness; inadequate nutrition; and reduced tissue elasticity.


Immobility creates pressure buildup at bony areas because patients are unable to redistribute pressure. Shearing occurs when layers of the skin slide over one another and the underlying tissues. It is mostly caused by pulling linen from beneath patients while the patients are still lying on it or when patients slide down in bed or chair ( www.molnlycke.com/patient/en/Wound/wounds/Pressure-ulcer/r ). Friction occurs when the skin is dragged across a surface because it causes damage to skin cells and minute blood vessels. Use of a draw sheet (during turning) helps to prevent friction. Decreased sensation to the area under pressure causes a pressure ulcer to develop; decreased cognition is also a factor because in both instances the patient is unaware of what is happening. Excessive moisture or dryness makes the skin highly susceptible to damage, because in both cases the skin becomes more fragile and breaks easily. Poor nutrition intake, especially vitamin C, protein, and zinc, can contribute to the possibility of skin breakdown. Reduced tissue elasticity, usually seen in the geriatric population, causes the skin to be thinner, making it much easier for tissue and blood vessel damage ( www.mayoclinic.com/health/bedsores/DS00570/DSECTION=risk-factors ).


Many patients in rehabilitation are at risk of skin breakdown because of immobility, insensate skin, impaired circulation, impaired cognition, and altered nutrition. Preventing pressure ulcers and preventing existing pressure ulcers from worsening is a hallmark of rehabilitation nursing ( Table 3 ). Rehabilitation nurses know the importance of positioning and turning patients, weight shifts when in the wheelchair, the use of specialized cushions and mattresses, the importance of good nutrition, and the importance of education.


Apr 17, 2017 | Posted by in PHYSICAL MEDICINE & REHABILITATION | Comments Off on Safety in the Rehabilitation Setting: A Nursing Perspective
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