Patient Safety, Communication, and Recordkeeping

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Chapter 3

Patient Safety, Communication, and Recordkeeping

Scott P. Marlow

Chapter Objectives

After reading this chapter you will be able to:

Describe how to apply good body mechanics and posture to moving patients.

Describe how to ambulate a patient and the potential benefits of ambulation.

Write definitions of key terms associated with electricity, including voltage, current, and resistance.

Identify the potential physiologic effects that electrical current can have on the body.

State how to reduce the risk of electrical shock to patients and yourself.

Identify key statistics related to the incidence and origin of hospital fires.

List the conditions needed for fire and how to minimize fire hazards.

Identify impediments to care and risk in the direct patient environment.

State how communication can affect patient care.

Describe the two patient identifier system.

List the factors associated with the communication process.

Describe how to improve your communication effectiveness.

Describe how to recognize and help resolve interpersonal or organizational sources of conflict.

List the common components of a medical record.

State the legal and practical obligations involved in recordkeeping.

Describe how to maintain a problem-oriented medical record.

problem-oriented medical record (POMR)

resistance

SOAP

voltage

Respiratory therapists (RTs) share the general responsibilities for providing a safe and effective health care environment with nurses and other members of the health care team. The continuum of patient safety requires that the RT have specific technical knowledge of the environment of direct patient care. In addition to technical skills, all health care professionals must be able to communicate effectively with each other and with patients and patients’ families and to document pertinent information. Figure 3-1 shows this relationship for patient safety. This chapter provides the foundation knowledge needed to assume these general aspects of patient care effectively.

Safety Considerations

Patient safety is always the first consideration in respiratory care. Although the RT usually does not have full control over the patient’s environment, efforts must be made to minimize potential hazards associated with respiratory care. The key areas of potential risk are patient movement and ambulation, electrical hazards, fire hazards, and general safety concerns.

Patient Movement and Ambulation

Basic Body Mechanics

Posture involves the relationship of the body parts to each other. A person needs good posture to reduce the risk of injury when lifting patients or heavy equipment. Poor posture may place inappropriate stress on joints and related muscles and tendons. Figure 3-2 illustrates the correct body mechanics for lifting a heavy object. The correct technique calls for a straight spine and use of the leg muscles to lift the object.

FIGURE 3-2 Body mechanics for lifting and carrying objects.

Moving the Patient in Bed

Conscious people assume positions that are the most comfortable. Bedridden patients with acute or chronic respiratory dysfunction often assume an upright position, with their arms flexed and their thorax leaning forward. This position helps decrease their work of breathing. In other cases, patients may have to assume certain positions for therapeutic reasons such as when postural drainage is applied.

Figure 3-3 shows the correct technique for lateral movement of a bed-bound patient. Figure 3-4 illustrates the ideal method for moving a conscious patient toward the head of a bed. Figure 3-5 shows the proper technique for assisting a patient to the bedside position for dangling his or her legs or transfer to a chair.

FIGURE 3-3 A, Method to pull a bed-bound patient. B, Method to push a bed-bound patient.

FIGURE 3-4 Method to move a patient up in bed with the patient’s assistance.

FIGURE 3-5 Method to assist a patient in dangling the legs at the side of the bed.

Mini Clini

“Tingling” Equipment

Problem

An RT is caring for a patient on a mechanical ventilator that requires both electrical and pneumatic power for operation. When the RT touches the metal housing of the ventilator, a shock is felt. How should the RT handle the situation based on this observation?

Discussion

All therapeutic instruments used in patient care, including mechanical ventilators, should be connected to grounded outlets (three-wire). Because the ground wire is a protection device only and not part of the main circuit, equipment may continue to operate without the clinician being aware that a problem exists. Because the RT felt a tingling sensation when touching the ventilator, this could represent an improper ground and possible serious current leakage. In this situation, the RT should immediately take the equipment out of service and get it replaced (while providing backup ventilation). All electrical equipment used in patient care should be routinely checked for appropriate grounding.

Electricity moves from point A to point B owing to differences in voltage. Voltage is the power potential behind the electrical energy. Low-voltage batteries (e.g., 9 V) are sufficient to power a small flashlight but inadequate to power a major appliance such as a microwave oven. Most homes and hospitals are powered with 120-V power sources. Power sources that have high voltage have the potential to generate large amounts of electrical current. The current that moves through an object is directly related to the voltage difference between point A and point B and inversely related to the resistance offered by the makeup of the object. Objects with low resistance (e.g., copper wires) allow maximum current to flow through the object. Objects with high resistance (e.g., rubber tubing) allow minimal or no current to flow through the object despite higher levels of voltage.

The simple analogy of water flowing through a piping system is useful to understand electricity. The water pressure level at the source is equivalent to the voltage. Higher water pressure provides the potential for greater water flow or current. The friction (resistance) offered by the pipe across the length of the pipe influences the flow exiting the other end. Pipes with lots of friction reduce the water flow (current) greatly. If the friction (resistance) is minimal, the water flow (current) is maximal. Similarly, when voltage is high and resistance is low, electrical current flows easily through the object.

The difference in resistance between two people or two objects explains why the same voltage applied to both can seriously damage one and cause no effect to the other. Two people accidentally touching a “hot” wire with 120 V can experience two completely different sensations. A person with wet skin offers little resistance, and the 120 V passes through the person with high current and can cause serious injury or death. A person with dry skin, which offers high resistance, may not even feel a shock and experiences no injury. The degree of resistance offered by the skin varies from person to person based on the chemistry of the person’s skin, the cleanliness of the skin, and the amount of moisture on the surface. For this reason, it is never wise to touch a potentially hot wire even though your skin is dry.

As stated before, voltage is the energy potential from an electrical source, and it is measured with a voltmeter. Current is the flow of electricity from a point of higher voltage to one of lower voltage and is reported in amperes (amps). Current is measured with an ampmeter. The resistance to electrical current is reported in ohms. We can determine the resistance to current for any object by the following equation:

< ?xml:namespace prefix = "mml" />Resistance(ohms[Ω])=Voltage(V)/Current(amps[A])

Current represents the greatest danger to you or your patients when electrical shorts occur. Voltage and resistance are important only because they determine how much current potentially can pass through the body. High voltage provides greater potential for high currents, but if resistance is also very high, current would be minimal or nonexistent. Current represents the potential danger to the patient. The harmful effects of current depend on (1) the amount of current flowing through the body, (2) the path it takes, and (3) the duration the current is applied. Higher currents (>100 milliamps [mA]) that pass through the chest can cause ventricular fibrillation, diaphragm dysfunction (owing to severe, persistent contraction), and death.

Because current is most important, you should be familiar with the equation used to calculate it:

Current(A)=Voltage(V)/Resistance(Ω)

For example, as long as a person is insulated by normal clothing and shoes and is in a dry environment, a 120-V shock may hardly be felt because the resistance is high in this situation (10,000 Ω). Current can be calculated as:

Current(A)=120V/10,000Ω=0.012A or12mA

Currents of 12 mA would cause a tingling sensation but no physical damage.

However, if the same person is standing without shoes on a wet floor, a much higher current occurs because the resistance is much lower (1000 Ω). The current is now calculated as:

Current(A)=120V/1000Ω=0.12A or120mA

Because the heart is susceptible to any current level greater than 100 mA, 120 mA represents a potentially fatal shock; this is in sharp contrast to the first example, where the same voltage caused only a tingling sensation.

A shock hazard exists only if the electrical “circuit” through the body is complete, meaning that two electrical connections to the body are required for a shock to occur. In the previous example, the person standing in water with no shoes has “grounded” himself. The finger touching the hot wire provides the input source while the feet standing in water provide the exit to ground. If the same person is wearing rubber boots, the connection to ground does not exist, and the current cannot flow through the individual.

In electrical devices, these two connections typically consist of a “hot” wire and a “neutral” wire. The neutral wire completes the circuit by taking the electrical current to a ground. A ground is simply a low-resistance pathway to a point of zero voltage, such as the earth (hence the term “ground”).

Figure 3-6 shows how current can flow through the body. In this case, a piece of electrical equipment is connected to AC line power via a standard three-prong plug. However, unknown to the practitioner, the cord has a broken ground wire. Normally, current leakage from the equipment would flow back to the ground through the ground wire. However, this pathway is unavailable. Instead, the leakage current finds a path of low resistance through the practitioner to the damp floor (an ideal ground).

FIGURE 3-6 Hazard created by broken ground wire.

Current can readily flow into the body, causing damage to vital organs when the skin is bypassed via conductors such as pacemaker wires or saline-filled intravascular catheters (Figures 3-7 and 3-8). Even urinary catheters can provide a path for current flow. The heart is particularly sensitive to electrical shock. Ventricular fibrillation can occur when currents of 20 µA (20 microamperes, or 20 millionths of 1 ampere) are applied directly to the heart.

FIGURE 3-7 Possible microshock hazard caused by patient grounding.

FIGURE 3-8 Possible hazard through use of certain cardiac monitors and a pacemaker.

Electrical shocks are classified into two types: macroshock and microshock. A macroshock exists when a high current (usually >1 mA) is applied externally to the skin. A microshock exists when a small, usually imperceptible current (<1 mA) bypasses the skin and follows a direct, low-resistance path into the body. Patients susceptible to microshock hazards are termed electrically sensitive or electrically susceptible. Table 3-1 summarizes the different effects of these two types of electrical shock.

TABLE 3-1

Effects of Electrical Shock *

Amperes (A)	Milliamperes (mA)	Microamperes (µA)	Effects
Applied to Skin (Macroshock)
≥6	>6000	>6,000,000	Sustained myocardial contraction followed by normal rhythm; temporary respiratory paralysis; burns, if small area of contact
0.1-3	100-3000	100,000	Ventricular fibrillation; respiratory center intact
0.050	50	50,000	Pain; fainting; exhaustion; mechanical injury; heart and respiratory function intact
0.016	16	16,000	“Let go” current; muscle contraction
0.001	1	1000	Threshold of perception; tingling
Applied to Myocardium (Microshock)
0.001	0.1	100	Ventricular fibrillation

Duration of exposure and current pathway are major determinants of human response to electrical shock.

^*Physiologic effects of AC shocks applied for 1 second to the trunk or directly to the myocardium.

Preventing Shock Hazards

Most shock hazards are caused by inappropriate or inadequate grounding. Shock hazards can be eliminated or minimized if wiring in patient care areas is appropriate and if all equipment brought into the patient care area has been UL approved and checked on a regular basis by a qualified person.

Ground Electrical Equipment Near the Patient

All electrical equipment (e.g., lights, electrical beds, ventilators, monitoring or therapeutic equipment) should be connected to grounded outlets with three-wire cords. In these cases, the third (ground) wire prevents the dangerous buildup of voltage that can occur on the metal frames of some electrical equipment.

Modern electrical devices used in hospitals are designed so that their frames are grounded, but their connections to the patient are not. In this manner, all electrical devices in reach of the patient are grounded, but the patient remains isolated from ground. Because the ground wire is simply a protection device and not part of the main circuit, equipment continues to operate normally even if the ground wire is broken. All electrical equipment, particularly devices used with electrically susceptible patients, must be checked for appropriate grounding on a regular basis by a qualified electrical expert.

Fire Hazards

In 1980, approximately 13,000 health care facility fires were officially reported in the United States.³ During the period 2004-2006, the average annual number of fires in health care facilities was 6400.⁴ This significant reduction in health care facility fires is primarily due to education and enforcement of strict fire codes.

About 23% of fires in health care facilities occur in hospitals, and 44% occur in nursing homes; the most common site of origin of the fire is the kitchen.³ About 15% of hospital fires start in patient care rooms and are usually due to patients or visitors smoking or using open flames to light tobacco products. Medical facility fires cause an annual average of five civilian deaths and approximately $34 million in damage.⁴

Hospital fires can be very serious, especially when they occur in patient care areas and when supplemental oxygen is in use. Fires in oxygen-enriched atmospheres (OEAs) are larger, more intense, faster burning, and more difficult to extinguish. In addition, some material that would not burn in room air would burn in OEAs. Hospital fires are also more serious because evacuation of critically ill patients is difficult and slow. For these reasons, hospital fires often cause more injuries and deaths per fire than do residential fires. For a fire to start, three conditions must exist: (1) flammable material must be present, (2) oxygen must be present, and (3) the flammable material must be heated to or above its ignition temperature. When all three conditions are present, a fire starts. Conversely, removing any one of the conditions can stop a fire from starting or extinguish it after it has begun. Fire is a serious hazard around respiratory care patients using supplemental oxygen. Although oxygen is nonflammable, it greatly accelerates the rate of combustion. Burning speed increases with an increase in either the concentration or the partial pressure of oxygen.

Flammable material should be removed from the vicinity of oxygen use to minimize fire hazards. Flammable materials include cotton, wool, polyester fabrics, bed clothing, paper materials, plastics, and certain lotions or salves such as petroleum jelly. Removal of flammable material is particularly important whenever oxygen enclosures, such as oxygen tents or croupettes, are used.

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