Develop a nursing policy based on a specific patient safety initiative. Include the following:
The specific patient safety initiative
Purpose of the policy
Policy objective – include desired metrics or outcomes
Identify roles that will be impacted by the policy
Policy statement
Policy details – thoroughly describe
How often will the policy be revised?
Who is responsible for oversight and monitoring? What will be measured to determine effectiveness of the policy?
Sample Answer
The Specific Patient Safety Initiative: Prevention of Hospital-Acquired Pressure Injuries (HAPIs)
Purpose of the Policy: The purpose of this policy is to establish clear guidelines and procedures for the proactive assessment, prevention, and management of pressure injuries among all patients admitted to [Healthcare Facility Name]. This policy aims to minimize the incidence of HAPIs, improve patient outcomes, enhance patient comfort, and reduce healthcare costs associated with the treatment of these preventable injuries.
Policy Objective: To reduce the incidence of Hospital-Acquired Pressure Injuries (HAPIs) by 20% within the next 12 months, as measured by:
- A decrease in the facility's HAPI rate per 1,000 patient days.
- An increase in documented Braden Scale assessments upon admission and every shift for at-risk patients.
- A reduction in the number of HAPI stages III, IV, and unstageable.
- Increased patient and family satisfaction related to skin care.
Roles That Will Be Impacted by the Policy:
- Registered Nurses (RNs): Primary responsibility for assessment, implementation of preventative measures, and documentation.
- Licensed Practical Nurses (LPNs): Assist RNs with preventative measures, turning, and repositioning.
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Full Answer Section
- Nursing Assistants/Patient Care Technicians (PCTs): Essential in assisting with repositioning, hygiene, and reporting changes in skin integrity.
- Charge Nurses/Nurse Managers: Responsible for policy adherence, staff education, and resource allocation.
- Wound Care Nurses/Specialists: Provide expert consultation, education, and manage complex pressure injuries.
- Physicians/Advanced Practice Providers (APPs): Responsible for ordering appropriate interventions, managing underlying medical conditions, and prescribing wound care treatments.
- Dietitians: Assess and recommend nutritional support to optimize skin integrity and healing.
- Physical and Occupational Therapists: Assist with mobility, repositioning techniques, and specialized seating/support surfaces.
- Patients and Families: Actively participate in their care by reporting discomfort or skin changes, and adhering to repositioning schedules where possible.
Policy Statement: [Healthcare Facility Name] is committed to providing safe, high-quality patient care, which includes the diligent prevention of hospital-acquired pressure injuries. All healthcare professionals involved in direct patient care are responsible for adhering to evidence-based practices for pressure injury prevention, ensuring timely assessment, proactive interventions, and comprehensive documentation to safeguard patient skin integrity.
Policy Details:
- Risk Assessment:
- All patients admitted to [Healthcare Facility Name] will have a comprehensive skin assessment and a Braden Scale risk assessment performed by a Registered Nurse within 8 hours of admission.
- The Braden Scale will be re-assessed at a minimum of every 12 hours for patients identified as "at risk" (Braden Scale score of 18 or less), or more frequently if the patient's condition changes.
- For patients in critical care or with rapidly changing conditions, Braden Scale assessment will occur every 4 hours or more frequently as clinically indicated.
- Prevention Strategies for At-Risk Patients:
- Repositioning: Patients identified as at risk for pressure injuries will be repositioned at least every 2 hours while in bed and every 1 hour while in a chair, unless contraindicated by their medical condition. Documentation of position changes is mandatory.