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?
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.
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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