Supplemental oxygen is sometimes required to meet a person’s oxygenation needs. Oxygen is not flammable, but fire needs oxygen to start and to keep burning. When more oxygen is in the air, a fire burns hotter and faster. Strict codes regulate the use and storage of medical oxygen in health care facilities. This is not necessarily true in the home environment. Hospital emergency departments see approximately 1190 thermal burns per year caused by ignitions associated with home medical oxygen (National Fire Protection Association, 2008). Smoking is by far the leading cause of burns, reported fires, deaths, and injuries involving home medical oxygen.

Be aware of factors in a patient’s environment that decrease the amount of available oxygen. A common environmental hazard in the home is an improperly functioning heating system. A furnace, stove, or fireplace that is not properly vented introduces carbon monoxide into the environment. Carbon monoxide affects a person’s oxygenation by binding with hemoglobin, preventing the formation of oxyhemoglobin and thus reducing the supply of oxygen delivered to tissues (see Chapter 40). Low concentrations cause nausea, dizziness, headache, and fatigue. Very high concentrations cause death after 1 to 3 minutes of exposure (National Fire Protection Association, 2010a).

Meeting nutritional needs adequately and safely requires environmental controls and knowledge (see Chapter 44). Health care facilities and restaurants are required to meet State Board of Health regulations. To protect consumers, commercially processed and packaged foods are subject to Food and Drug Administration (FDA) regulations. The FDA is a federal agency responsible for the enforcement of federal regulations regarding the manufacture, processing, and distribution of foods, drugs, and cosmetics to protect consumers against the sale of impure or dangerous substances. Although food supply in the United States is one of the safest in the world, each year about 76 million illnesses occur, more than 300,000 persons are hospitalized, and 5,000 die from foodborne illness (Centers for Disease Control and Prevention, 2009). Groups at the highest risk are children, pregnant women, older adults, and people with compromised immune systems. Foods that are inadequately prepared or stored or subject to unsanitary conditions increase the patient’s risk for infections and food poisoning.

A person’s comfort zone is usually between 18.3° and 23.9° C (65° and 75° F). Temperature extremes that frequently occur during the winter and summer affect comfort, productivity, and safety. Exposure to severe cold for prolonged periods causes frostbite and accidental hypothermia. Frostbite occurs when a surface area of the skin freezes as a result of exposure to extremely cold temperatures. Hypothermia occurs when the core body temperature is 35° C (95° F) or below. Older adults, the young, patients with cardiovascular conditions, patients who have ingested drugs or alcohol in excess, and people who are homeless are at high risk for hypothermia. Exposure to extreme heat changes the electrolyte balance of the body and raises the core body temperature, resulting in heatstroke or heat exhaustion. Chronically ill patients, older adults, and infants are at greatest risk for injury from extreme heat. These patients need to avoid extremely hot, humid environments (see Chapter 29).

Vehicle design and equipment such as seat belts, air bags, and laminated windshields (remain in one piece when impacted) have improved safety for vehicle occupants. State specific laws relating to young driver licensing, safety belt use, child restraint use, and motorcycle helmets exist for protection. Child safety seats and booster seats appropriate for the child’s age and weight and the type of car need to be used (Fig. 27-1). The American Academy of Pediatrics (2011) recommends that all infants and toddlers ride in the back seat with a rear-facing car safety seat until they are 2 years of age or they reach the highest weight or height allowed by the manufacturer of the car safety seat. The website of the Academy, Healthy Children, http://www.aap.org/healthtopics/carseatsafety.cfm, has information for children of all ages and the type of safety seat to use. The back seat of a car is the safest part of the vehicle in the event of a crash and prevents injury from deployment of passenger and side air bags. According to the Centers for Disease Control and Prevention (2010b), the risk of motor vehicle accidents is higher among 16- to 19-year-old drivers than any other age-group. Teens are more likely to underestimate dangerous situations or not be able to recognize hazardous situations, speed and allow shorter headways, ride with intoxicated drivers, and drive after using alcohol and drugs. Teens also have the lowest rate of seat belt use. Older drivers are keeping their licenses longer and driving more miles than in the past. Per mile traveled, fatal crash rates increase starting at age 75 and increase markedly after age 80 (Insurance Institute for Highway Safety, 2008). An older adult is not always able to quickly observe situations in which an accident is likely to occur. Decreased hearing acuity alters the ability to hear emergency vehicle sirens or vehicle horns. Because of decreased nervous system response, older adults are unable to react as quickly as they once could to avoid an accident. A decline in these skills accounts for the most common types of accidents, including right-of-way and turning accidents.

A poison is any substance that impairs health or destroys life when ingested, inhaled, or absorbed by the body. Almost any substance is poisonous if too much is taken. Sources in a person’s home include drugs, medicines, other solid and liquid substances, and gases and vapors. Poisons often impair the function of every major organ system. Health care providers are at risk from chemicals such as toxic cleaning agents. In the home accidental poisoning is a greater risk for toddlers, preschoolers, and young school-age children, who often ingest household cleaning solutions, medications, or personal hygiene products. Emergency treatment is necessary when a person ingests a poisonous substance or comes in contact with a chemical that is absorbed through the skin. In 2008 more than 2000 people a day were seen in emergency departments after a poison incident (Centers for Disease Control and Prevention, 2010c). Specific antidotes or treatments are available only for some types of poisons. A poison control center is the best resource for patients and parents needing information about the treatment of an accidental poisoning.

Although lead has not been used in house paint or plumbing materials since the U.S. Consumer Product Safety Commission banned it in 1978, older homes in poorer communities continue to contain high lead levels. Soil and water systems are sometimes contaminated. Poisoning occurs from swallowing or inhaling lead. Fetuses, infants, and children are more vulnerable to lead poisoning than adults because their bodies absorb lead more easily and small children are more sensitive to the damaging effects of lead. Exposure to excessive levels of lead affects a child’s growth or causes learning and behavioral problems and brain and kidney damage (Agency for Toxic Substances and Disease Registry, 2010).

Falls are a major public health problem. Among adults 64 years and older, falls are the leading cause of unintentional death (Centers for Disease Control and Prevention, 2010a). Numerous factors increase the risk of falls, including a history of falling, being age 65 or over, reduced vision, orthostatic hypotension, gait and balance problems, urinary incontinence, use of walking aids, and the effects of various medications (e.g., anticonvulsants, hypnotics, sedatives, certain analgesics) (Deandrea et al., 2010). Common physical hazards that lead to falls include inadequate lighting, barriers along normal walking paths and stairways, and a lack of safety devices in the home. Often a fall leads to serious injury such as fractures or internal bleeding. Patients most at risk for injury are those with bleeding tendencies resulting from disease or medical treatments and osteoporosis. Injuries frequently result from accidental contact with objects on stairs, floors, bedside tables, closet shelves, refrigerator tops, and bookshelves. Children fall from anywhere (i.e., trees, wall/fences, playground equipment, furniture, and moving objects such as skateboards and bicycles). Forces from falls lead to injury with variable severity, depending on the height of the fall, body position on impact, and impact surface.

A total of 386,500 home fires were reported in the United States in 2008, resulting in 2,755 deaths and 13,160 injuries (National Fire Protection Association, 2010b). The leading cause of fire-related death is careless smoking, especially when people smoke in bed at home. The improper use of cooking equipment and appliances, particularly stoves, is the main source for in-home fires and fire injuries. Smoke detectors and carbon monoxide detectors need to be placed strategically throughout a home. Multipurpose fire extinguishers need to be near the kitchen and any workshop areas.

When they strike, natural disasters such as floods, tsunamis, hurricanes, tornadoes, and wildfires are a major cause of death and injury. These types of disasters result in death and leave many people homeless. Every year millions of Americans face disaster and its terrifying consequences (FEMA, 2010). Bioterrorism is another cause of disaster. Threats of this type come in the form of biological, chemical, and radiological attacks. Bioterrorism, or the use of biological agents to create fear and threat, is the most likely form of a terrorist attack to occur. Although terrorists could use any agent, health officials are most concerned with biological agents such as anthrax, smallpox, pneumonic plague, botulism, tularemia, and viral hemorrhagic fevers (American Medical Association, 2010).

Injuries are the leading cause of death in children over age 1 and cause more death and disabilities than do all diseases combined (Hockenberry and Wilson, 2009). The nature of the injury sustained is closely related to normal growth and development. For example, the incidence of lead poisoning is highest in late infancy and toddlerhood. Children at this stage explore the environment and, because of their increased level of oral activity, put objects in their mouth. This increases risk for poisoning and choking. Fire often results from their curiosity in playing with matches. In addition, limited physical coordination contributes to falls from bicycles and playground equipment. Additional injuries at this age are related to riding unrestrained in a motor vehicle, drowning, and head trauma from objects. Accidents involving children are largely preventable, but parents need to be aware of specific dangers at each stage of growth and development. Accident prevention thus requires health education for parents and the removal of dangers whenever possible.

When a child enters school, the environment expands to include the school, transportation to and from school, school friends, and after-school activities. School-age children are learning how to perform more complicated motor activities and often are uncoordinated. Parents, teachers, and nurses need to instruct children in safe practices to follow at school or play, including what to do if approached by strangers. Teach school-age children involved in team and contact sports the rules for playing safely and how to use protective safety equipment such as helmets and other protective gear. Head injuries are a major cause of death, with bicycle accidents being one of the major causes of such injuries (Hockenberry and Wilson, 2009). Bikes need to be the proper size for the child, and helmets must be worn (Fig. 27-2). Additional injuries in this age-group are decreased by properly using seat belts and booster seats in motor vehicles and providing pedestrian safety education.

As children enter adolescence, they develop greater independence and begin to develop a sense of identity and their own values. The adolescent begins to separate emotionally from his or her family, and peers generally have a stronger influence. Wide variations that swing from childlike to mature behavior are characteristic of adolescent behavior (Hockenberry and Wilson, 2009). In an attempt to relieve the tensions associated with physical and psychosocial changes and peer pressures, some adolescents engage in risk-taking behaviors such as smoking, drinking alcohol, and using drugs. This increases the incidence of accidents such as drowning and motor vehicle accidents. When adolescents learn to drive, their environment expands, and so does their potential for injury. Fortunately teen motor vehicle crashes are preventable by avoiding distractions such as using cell phones, texting, eating, and drinking while driving.

To assess for possible substance abuse, have parents look for environmental and psychosocial clues from their children. Environmental clues include the presence of drug-oriented magazines, beer and liquor bottles, drug paraphernalia and blood spots on clothing and the continual wearing of long-sleeved shirts in hot weather and dark glasses indoors. Psychosocial clues include failing grades, change in dress, increased absenteeism from school, isolation, increased aggressiveness, and changes in interpersonal relationships. Because adolescence is a time when mature sexual physical characteristics develop, some adolescents begin to have physical relationships with others that present the risk of sexually transmitted diseases.

The physiological changes associated with aging, effects of multiple medications, psychological factors, and acute or chronic disease increase the older adult’s risk for falls and other types of accidents. Falls often result in bruises, hip fractures, or head trauma. The risk of being seriously injured in a fall increases with age. Older patients are more likely to fall in the bedroom, bathroom, and kitchen. Environmental factors such as broken stairs, icy sidewalks, inadequate lighting, throw rugs, and exposed electrical cords cause many of the accidents. Inside falls most often occur while transferring from beds, chairs, and toilets; getting into or out of bathtubs; tripping over items such as cords covered by rugs or carpets, carpet edges, or doorway thresholds; slipping on wet surfaces; and descending stairs. Fear of falling is a concern of community-dwelling older adults, and many avoid activities because of their fear (Zijlstra et al., 2007). Falls can be decreased by multiple-component group exercise, Tai Chi, having a physician or pharmacist review all medications, having an eye examination annually, and decreasing hazards in the home that increase falls (Gillespie et al., 2009).

Cognitive impairments associated with delirium, dementia, and depression place patients at greater risk for injury. These conditions contribute to altered concentration and attention span, impaired memory, and orientation changes. Patients with these alterations become easily confused about their surroundings and are more likely to have falls and burns. Patients with visual, hearing, tactile, or communication impairment such as aphasia or a language barrier are not always able to perceive a potential danger or express their need for assistance (see Chapter 49).

Falls result in minor to severe injuries such as hip fractures or head trauma that result in reduced mobility and independence and increase the risk for premature death. Patients who have underlying disease states are more susceptible to fall-related injuries (Hughes, 2008). For example, a patient with a bleeding disorder is more likely to have an intracranial bleed; a patient with osteoporosis has a greater chance for fracture. The unfamiliar environment, acute illness, surgery, mobility status, medications, treatments, and placement of various tubes and catheters are common challenges that place patients of any age at risk of falling. Factors the nurse can influence include assessment and communication about patient risks, information access, signage, the environment, teamwork, and involving the patient and family (Dykes et al., 2009). Falls that result in injuries often extend a patient’s length of stay in the health care environment, placing them at an even greater risk for other complications.

Procedure-related accidents are caused by health care providers and include medication and fluid administration errors, improper application of external devices, and accidents related to improper performance of procedures such as dressing changes or urinary catheter insertion. Nurses are able to prevent many procedure-related accidents by adhering to organizational policy and procedures and standards of nursing practice. For example, proper preparation and administration of medications, use of patient and medication bar coding, and “Smart” intravenous (IV) pumps reduce medication errors (see Chapters 31 and 41). All staff need to be aware that distractions and interruptions contribute to procedure-related accidents and need to be limited, especially during high-risk procedures such as medication administration. The potential for infection is reduced when surgical asepsis is used for sterile dressing changes or any invasive procedure such as insertion of a urinary catheter. Finally, correct use of safe patient handling techniques and equipment reduces the risk of injuries when moving and lifting patients (see Chapter 47).

Accidents that are equipment related result from the malfunction, disrepair, or misuse of equipment or from an electrical hazard. To avoid rapid infusion of IV fluids, all general-use and patient-controlled analgesic pumps need to have free-flow protection devices. To avoid accidents, do not operate monitoring or therapy equipment without adequate instruction. If faulty equipment is discovered, place a tag on it to prevent it from being used on another patient and promptly report any malfunctions. Assess potential electrical hazards to reduce the risk of electrical fires, electrocution, or injury from faulty equipment. In health care settings the clinical engineering staff make regular safety checks of equipment. Facilities must report all suspected medical device—related deaths to both the FDA and the manufacturer of the product if known (FDA, 2009). This is usually done in conjunction with the risk management department after tagging and removing the piece of equipment.

Assessment of a patient’s risk factors for falling is essential in determining specific needs and developing targeted interventions to prevent falls. Many different fall assessment instruments are available; use the tool chosen by your health care agency. A fall assessment tool (Table 27-1) helps you assess important risk factors. At a minimum the assessment needs to be completed on admission, following a change in the patient’s condition, after a fall, and when transferred. If it is determined that the patient is at risk for falling, regular assessment always continues. In many cases family members are important resources in assessing a patient’s fall risk. Families often are able to report on the patient’s level of confusion and ability to ambulate. Based on the results of a fall risk assessment, you implement multiple evidence-based interventions. It is very important to inform a patient and family members about the patient’s risks. Often younger patients are not aware of how medications and treatments cause dizziness, orthostatic hypotension, or changes in balance. When patients are unaware of their risks, they are less likely to ask for assistance. If family members are informed, they will often call for help (when they are visiting patients) to be sure that patients are appropriately assisted.

Be alert to factors within your own work environment that create conditions in which medical errors are more likely to occur. Studies show that overwork and fatigue cause a significant decrease in alertness and concentration, leading to errors (Trinkoff et al., 2006). It is important for you to be aware of these factors and include checks and balances when working under stress. For example, to reduce the potential for a medical error, it is essential for you to check the patient’s identification by using two identifiers (e.g., name and birthday or name and account number) according to facility policy before beginning any procedure or administering a medication (see Chapter 31).

Hospitals must be prepared to respond and care for a sudden influx of patients at the time of a community disaster. Guidelines for a disaster response are included in a facility emergency management plan. All hospitals conduct disaster drills on a routine basis. Communication is a key to any emergency management plan. Nurses must know what happened, how many patients to expect, and when patients will begin to arrive so they can prepare both themselves and their facility. Although the occurrence of a bioterrorist attack has been limited to the anthrax deaths following September 11, 2001, the threat is very real. Be prepared to make accurate and timely assessments in any type of setting. A bioterrorist attack will likely resemble a natural outbreak initially. Acutely ill patients representing the earliest cases after a covert attack seek care in emergency departments. Patients less ill at the onset of an illness possibly seek care in primary care settings. Basic epidemiological principles exist to assess whether a patient’s presentation of symptoms is typical of an endemic disease or an unusual event that raises concern. Features that alert nurses to the possibility of a bioterrorism-related outbreak include the following (Dire, 2008):