Nursing is a practice based profession. Though all aspects of nursing education are important, the clinical setting is where everything that has been taught in the classroom and skills lab must be able to be tied together and safely applied to the bedside

A 4.0 classroom theory grade means little if that same student cannot transfer learning correctly and safely to the bedside where it matters most. Therefore, clinical education must be the greatest strength of any program in order to maximize the learning of students and prepare them for professional practice.

Safety is a unifying thread as a foundation for practice that goes far beyond the safe “rights” of medication administration but must encompass everything that is done in clinical practice.

What a Nurse & Pilot Have in Common

Just as a pilot has a written checklist that must be checked off before the plane is safe to leave the runway, experienced nurses also have a similar safety checklist that is internalized that must be intentionalized for students.

As I reflect on my own 30+ years in clinical practice and how I systematically go through my mental “safety checklist” with each patient I care for, I want to share how I translate this culture and attitude of safety to my students.

Once a student has received report at the change of shift, if they were the primary nurse, they are also responsible for any inherited errors that may be present in the patient’s room even though they were not directly responsible for them.

In order to provide safe care in every aspect related to the patients your students will care for, I have developed the following aspects from my own practice to be a relevant safety “checklist” of essential safety assessments to review as the student enters the room for the FIRST TIME. Modify this list as needed depending on your clinical practice setting.

General Safety Principles

Tab alarms

Make sure that any device that is related to preventing a patient fall is properly working. Tab alarms must be properly secured to the patient in order for them to release and alarm.

Level of bed/side rails

Be sure to note if the bed is down at the lowest position as well as the side rails being up or down depending on the need and concern for safety.

Miscellaneous

• Are assistive devices available to the patient and at the bedside
• How many staff to transfer patient safely identified?
• Any adaptive equipment needed and in place for bathroom safety?

Room order

• Though the nurse may have inherited a messy room, it is not okay to leave it that way! A room that is clean and in order is a room that promotes a healing environment. This emphasis goes all the way back to Nightingale! Therefore, this should always be a priority for the nurse. Do what is needed to bring order and cleanliness to every patient’s room.
• Make sure that the patient has fresh water and all old trays and food that may no longer be safe are removed
• Remember that the floor of any care setting is obviously dirty and contaminated. One of my pet peeves is the frequency I find sequential compression device (SCD’s) sleeves that go around the lower legs of the patient on the floor when they are not in use! Do not be that nurse. Keep them off the floor and as clean as possible!

Make it a priority to determine if the IV site is patent or not.

• From my clinical experience I have seen an IV patent who after just a few minutes can be leaking and obviously infiltrated. The most common signs that you will see clinically with IV infiltration is leakage of fluid at the insertion site, pain, and obvious swelling distal to the insertion site.

Is IV well secured?

• It is not uncommon for a peripheral IV to be poorly secured or the tape peeling off when you assess it for the first time. It is not good for your student or the patient to have this IV pull out and need to be restarted if it did not have to be. Encourage students to carry tape with them and secure it immediately as needed.

Is IV dressing intact?

• The clear Tegaderm® dressing can peel on the edges to such a degree that the insertion site is compromised. This is especially important to determine site integrity with any type of central line because of the risk of sepsis. If peeling on the edges but site intact, reinforce with tape. If site compromised or bloody, change dressing per hospital protocol ASAP!

Assessment of IV fluids

Determine that the IV solution is exactly what is ordered on the Medication Administration Record (MAR).

• A common error that I have observed is related to the similarities of many IV fluids such as D5 0.9% NS vs. D5 0.45% NS.

Assessment of IV rate

Confirm that the IV rate is exactly what is ordered on the MAR.

• These rates can change frequently and might have been missed by the prior nurse. Double-check the MAR with the correct rate as an essential safety check at the beginning of your shift.

Oxygen Assessments

• This is especially important if the patient has a history of COPD and is on a specific flow rate at home. This flow rate must be the same to ensure adequate oxygenation if their oxygenation needs have not increased as a result of being hospitalized.
• If there is no specific rate that the physician has ordered but instead has an order to keep oxygenation greater than 92 percent, once a complete assessment of your patient has been made, encourage students not to hesitate to wean and decrease this rate if the oxygenation is greater than the minimum percentage ordered to advance the plan of care.
• For example, I have cared for many patients who are on oxygen per nasal cannula with O2 sat of 100 percent who had been documented for two to three shifts at 100 percent and were able to be promptly weaned to room air with no significant drop in O2 sat.

 In Closing

Though this list is only a start, add to it with unique distinctives related to your clinical setting. If you are a clinical educator, do not hesitate to write down and create your own safety checklist for your students.

As novice nurses, the neuronal “ruts” that are deepened with repetitive practice are not well established in your students. Therefore anything that an educator can do to help students remember what is most important will always be welcomed and appreciated by your students.

Next week I will complete the safety checklist relating to essential assessments relating to NG tubes and chest tubes.

Comment Question:
What is the essence of your safety checklist that you communicate to your students to create and establish a culture of safety?
Comment below and let the conversation begin!