Safety and Infection Control

Master safety and infection control principles with free flashcards and spaced repetition practice. This lesson covers accident prevention, standard and transmission-based precautions, safe equipment use, and emergency response—essential concepts for passing the NCLEX-RN exam and protecting patients in clinical practice.

Welcome to Safe and Effective Care Environment: Safety and Infection Control 🏥

As a registered nurse, you are the frontline defender against healthcare-associated infections (HAIs) and preventable patient injuries. According to the CDC, approximately 1 in 31 hospital patients has at least one healthcare-associated infection on any given day, and many of these are preventable through proper safety protocols and infection control measures.

This lesson builds on management of care principles by focusing specifically on the technical and procedural aspects of maintaining a safe healthcare environment. You'll learn how to identify hazards, prevent transmission of infectious agents, respond to emergencies, and use equipment safely—all critical competencies tested on the NCLEX-RN exam.

Core Concepts: The Foundation of Patient Safety 🛡️

Standard Precautions: Your First Line of Defense

Standard precautions are infection control practices designed to prevent transmission of diseases through contact with blood, body fluids, non-intact skin, and mucous membranes. These precautions apply to ALL patients, regardless of known infection status, because you cannot always determine who is infectious.

💡 Memory Device - "GLAD HRS" for Standard Precautions:

• Gloves
• Linen (proper handling)
• Aseptic technique
• Disposal (sharps and waste)
• Hand hygiene
• Respiratory hygiene
• Sterile equipment when needed

Hand Hygiene: The Single Most Important Intervention

Hand hygiene is the #1 way to prevent healthcare-associated infections. The World Health Organization identifies 5 critical moments for hand hygiene:

┌────────────────────────────────────────────────┐
│     WHO 5 MOMENTS FOR HAND HYGIENE             │
└────────────────────────────────────────────────┘

    1️⃣ BEFORE                2️⃣ BEFORE
   Patient Contact        Aseptic/Clean Procedure
          │                       │
          ↓                       ↓
    ┌──────────────────────────────────┐
    │        👤 PATIENT                │
    │    (and surroundings)            │
    └──────────────────────────────────┘
          ↑                       ↑
          │                       │
    3️⃣ AFTER                 4️⃣ AFTER
   Body Fluid              Patient Contact
   Exposure Risk
          │
          ↓
    5️⃣ AFTER Contact with Patient Surroundings

Alcohol-Based Hand Rub (ABHR) is preferred when hands are not visibly soiled. Use soap and water when:

• Hands are visibly dirty or soiled with blood/body fluids
• After caring for patients with Clostridioides difficile (C. diff) - alcohol doesn't kill spores!
• After caring for patients with norovirus
• Before eating

Proper handwashing technique takes 40-60 seconds; ABHR takes 20-30 seconds.

Transmission-Based Precautions: Additional Barriers

When standard precautions alone are insufficient, transmission-based precautions provide extra protection based on the route of transmission. These are used IN ADDITION TO standard precautions.

Type	Route	PPE Required	Examples of Diseases
🚪 Contact	Direct/indirect contact with patient or environment	Gown + Gloves (private room preferred)	MRSA, VRE, C. diff, scabies, impetigo, RSV in infants
💨 Droplet	Large respiratory droplets (>5 microns) - travel <6 feet	Surgical mask (within 6 feet)	Influenza, pertussis, pneumonic plague, meningococcal disease, mumps
☁️ Airborne	Small particles (<5 microns) - remain airborne, travel far	N95 respirator + negative pressure room	TB, measles, varicella (chickenpox), disseminated herpes zoster

🧠 Memory Device - "My Chickens Turn Better, Really!" for Airborne Diseases:

• Measles
• Chickenpox (varicella)
• Tuberculosis (TB)
• (Plus disseminated herpes Zoster - ok, memory device not perfect!)

⚠️ Critical Distinction: Droplet vs. Airborne

• Droplet precautions = surgical mask (droplets fall within 6 feet)
• Airborne precautions = N95 respirator (particles stay suspended in air)

💡 Fit-testing for N95 respirators is required annually and whenever a different model is used. Seal-check should be performed each time you don the respirator.

Personal Protective Equipment (PPE): Donning and Doffing Sequence

The order matters to prevent contamination!

┌──────────────────────────────────────┐
│    DONNING PPE (Putting On) 👕       │
├──────────────────────────────────────┤
│                                      │
│  1. HAND HYGIENE 🧼                  │
│           ↓                          │
│  2. GOWN (ties in back)              │
│           ↓                          │
│  3. MASK or RESPIRATOR               │
│           ↓                          │
│  4. GOGGLES or FACE SHIELD           │
│           ↓                          │
│  5. GLOVES (over gown cuffs)         │
│                                      │
└──────────────────────────────────────┘

┌──────────────────────────────────────┐
│    DOFFING PPE (Taking Off) 🗑️       │
├──────────────────────────────────────┤
│  Remove MOST CONTAMINATED items      │
│  FIRST, LEAST contaminated LAST      │
│                                      │
│  1. GLOVES (most contaminated!)      │
│           ↓                          │
│  2. HAND HYGIENE 🧼                  │
│           ↓                          │
│  3. GOGGLES/FACE SHIELD              │
│           ↓                          │
│  4. GOWN                             │
│           ↓                          │
│  5. HAND HYGIENE 🧼                  │
│           ↓                          │
│  6. MASK/RESPIRATOR (least contact)  │
│           ↓                          │
│  7. HAND HYGIENE 🧼 (final!)         │
│                                      │
└──────────────────────────────────────┘

⚠️ Common Error: Students often forget hand hygiene between removing gloves and removing other PPE. Remember: gloves are heavily contaminated—clean your hands immediately after removal!

Sterile Technique vs. Clean Technique

Understanding when to use sterile (aseptic) versus clean (medical asepsis) technique is crucial:

Sterile Technique (Surgical Asepsis):

• Complete absence of microorganisms
• Used for: invasive procedures, surgery, inserting urinary catheters, central line dressing changes, preparing IV medications
• Key principles:
  • Sterile touches sterile only
  • Sterile field is at waist level or above (anything below waist is contaminated)
  • Edges (1 inch border) of sterile field are contaminated
  • Moisture allows microorganisms to wick through—wet = contaminated
  • Reaching over a sterile field contaminates it
  • Turn away from sterile field when coughing/sneezing

Clean Technique (Medical Asepsis):

• Reduces number of microorganisms
• Used for: routine patient care, administering oral medications, feeding patients
• Includes: handwashing, gloves, standard precautions

Accident and Injury Prevention 🚨

Fall Prevention: A National Patient Safety Goal

Falls are the most common adverse event in hospitals. The Joint Commission designates fall prevention as a National Patient Safety Goal.

Fall Risk Assessment Tools:

• Morse Fall Scale (most common in acute care)
• Hendrich II Fall Risk Model
• STRATIFY tool

Assessments should be performed:

• On admission
• After any change in condition
• After a fall
• With transfer to different unit
• Per facility policy (often every shift for high-risk patients)

Fall Prevention Interventions:

• ✅ Bed in lowest position with wheels locked
• ✅ Call light within reach, answer promptly
• ✅ Non-skid footwear
• ✅ Adequate lighting (especially at night)
• ✅ Toileting schedule (most falls occur going to/from bathroom)
• ✅ Remove clutter, keep pathways clear
• ✅ Assistive devices within reach
• ✅ Hourly rounding ("4 P's": Pain, Potty, Position, Possessions)
• ✅ Yellow arm bands/door signs for high-risk patients

❌ What NOT to do: Restraints increase fall risk when patients struggle against them. Use restraints only as a last resort.

Restraints and Seclusion: Legal and Ethical Considerations

Restraints are devices or medications that restrict patient movement. They require specific protocols:

Legal Requirements:

• Physician/Provider order required within 1 hour of application (may implement in emergency, but order must follow quickly)
• Order must be time-limited: 4 hours for adults, 2 hours for ages 9-17, 1 hour for children under 9
• Must try least restrictive alternatives first
• Face-to-face assessment by physician/provider within 1 hour for violent/self-destructive behavior; 4 hours for non-violent/non-self-destructive
• Patient must be reassessed every 15-30 minutes
• Document: reason for restraint, alternatives tried, patient response, monitoring

Nursing Care for Restrained Patients:

• Check circulation, sensation, skin integrity every 15-30 minutes
• Release restraints and provide range of motion every 2 hours
• Assist with toileting, nutrition, hydration
• Reassess need for continuation frequently
• Never tie restraints to side rails (could injure patient if rails lowered)
• Ensure quick-release knots

💡 Alternatives to restraints: reorientation, family presence, diversional activities, pain management, toileting schedule, bed/chair alarms, moving patient closer to nurses' station.

Safe Use of Equipment and Medical Devices

Biological hazards, equipment malfunction, and user error can all cause patient harm.

Key Safety Principles:

1. Alarms: Never silence or disable alarms. Alarm fatigue is real, but alarms save lives. Address the cause of the alarm.

2. Bed/chair alarms: Use for fall-risk patients. Respond immediately when alarm sounds.

3. IV pumps: Double-check programming before starting infusion. Use "smart pumps" with dose-error reduction software when available. Never bypass safety alerts without careful consideration.

4. Sequential compression devices (SCDs): Check skin integrity, ensure proper fit, confirm device is functioning (should inflate/deflate cyclically).

5. Patient-controlled analgesia (PCA): Patient presses button ONLY—never let family members press it. Monitor respiratory rate and sedation level closely.

6. Transfer equipment: Use mechanical lifts for patients who cannot bear weight. Follow weight limits. Inspect equipment before each use.

Ergonomics and Body Mechanics:

Healthcare workers have high rates of musculoskeletal injuries, especially back injuries. Proper body mechanics protect you:

• Use your legs, not your back
• Keep load close to your body
• Avoid twisting—pivot with your feet
• Get help for heavy or awkward lifts
• Use mechanical lifts whenever possible
• Maintain a wide base of support (feet shoulder-width apart)
• Tighten core muscles before lifting

⚠️ Never attempt to lift a patient alone if you're unsure. Injuring yourself helps no one.

Emergency Response and Disaster Preparedness 🚑

Fire Safety: RACE and PASS

In a healthcare facility fire emergency, remember RACE:

┌────────────────────────────────────┐
│     🔥 FIRE EMERGENCY: RACE       │
├────────────────────────────────────┤
│                                    │
│  R = RESCUE/REMOVE patients in     │
│      immediate danger              │
│           ↓                        │
│  A = ACTIVATE the fire alarm       │
│      (pull station)                │
│           ↓                        │
│  C = CONFINE/CONTAIN the fire      │
│      (close doors/windows)         │
│           ↓                        │
│  E = EXTINGUISH (if small) or      │
│      EVACUATE (if large)           │
│                                    │
└────────────────────────────────────┘

To use a fire extinguisher, remember PASS:

• Pull the pin
• Aim at the base of the fire
• Squeeze the handle
• Sweep side to side

Types of fires and appropriate extinguishers:

• Class A (paper, wood, cloth): Water or multipurpose
• Class B (flammable liquids): CO₂ or dry chemical
• Class C (electrical): CO₂ or dry chemical (never water!)
• Class ABC (multipurpose): Most common in healthcare

Code Response

Healthcare facilities use standardized codes for emergencies:

Code	Emergency Type	Initial Nursing Response
Code Blue	Cardiac/respiratory arrest	Call for help, start CPR, bring crash cart
Code Red	Fire	RACE protocol
Code Pink	Infant/child abduction	Secure unit exits, observe for suspicious persons
Code Gray	Combative person	Remove other patients from area, call security
Code Silver	Weapon/active shooter	RUN, HIDE, or FIGHT (as last resort)
Code Orange	Hazardous material spill	Evacuate area, call hazmat team
Code Yellow	Bomb threat	Do not use radios/phones near suspicious package

Note: Color codes may vary by facility. Always learn your specific facility's system during orientation.

Hazardous Materials and Spills

Safety Data Sheets (SDS), formerly called MSDS, provide information about chemical hazards. All healthcare facilities must maintain SDS binders and make them accessible to staff.

Spill Response:

For small spills (you can clean up yourself):

1. Don appropriate PPE (gloves minimum, may need gown/goggles)
2. Contain the spill
3. Clean up following facility protocol
4. Dispose of materials in appropriate container
5. Document

For large spills or chemical exposures:

1. Evacuate the area
2. Call for specialized hazmat team
3. Isolate the area
4. Notify supervisor immediately

Specific Hazards:

Cytotoxic drugs (chemotherapy):

• Require special handling protocols
• Use chemotherapy spill kit
• Don protective equipment before handling
• Never recap needles
• Use Luer-lock connections

Mercury spills (from broken thermometers/sphygmomanometers):

• Do NOT vacuum (spreads mercury vapor)
• Use mercury spill kit
• Ventilate area
• Never touch with bare hands

Biological hazards:

• Blood/body fluid spills: Use absorbent material, then disinfect with EPA-registered disinfectant or 1:10 bleach solution
• Sharps: Never pick up with hands. Use mechanical device (forceps, dustpan and broom)

Sharps Safety and Needlestick Injuries

Needlestick injuries expose healthcare workers to bloodborne pathogens (HIV, Hepatitis B, Hepatitis C).

Prevention:

• Use safety-engineered devices (self-sheathing needles, needleless systems)
• Never recap needles (most injuries occur during recapping)
• Dispose immediately in puncture-resistant sharps container
• Don't overfill sharps containers (replace when 2/3 full)
• Activate safety mechanism before disposal
• Never pass sharps hand-to-hand (use neutral zone)

If needlestick injury occurs:

1. Wash area immediately with soap and water (do NOT squeeze/scrub)
2. Report to supervisor and employee health/infection control immediately
3. Document circumstances: source patient, type of device, depth of injury
4. Source patient testing (with consent): HIV, HBV, HCV
5. Baseline testing for exposed worker
6. Post-exposure prophylaxis (PEP) if indicated—must start within 2 hours for HIV (up to 72 hours, but sooner is better)
7. Follow-up testing at 6 weeks, 3 months, 6 months

Examples: Applying Safety Principles in Clinical Scenarios 🎯

Example 1: Choosing Appropriate Precautions

Scenario: You are admitting four new patients. Determine the transmission-based precautions needed:

Patient A: 68-year-old with pneumonia, sputum culture pending Patient B: 45-year-old with active pulmonary tuberculosis Patient C: 32-year-old with MRSA wound infection on leg Patient D: 8-year-old with chickenpox (varicella)

Analysis:

• Patient A: Start with droplet precautions (pneumonia could be bacterial like pneumococcal or viral like influenza). If tuberculosis is suspected, upgrade to airborne. Once culture results return, adjust precautions accordingly.

• Patient B: Airborne precautions required. TB bacteria are transmitted via airborne nuclei. Patient needs negative-pressure room, you need N95 respirator. Patient should wear surgical mask during transport.

• Patient C: Contact precautions. MRSA is spread by direct contact or contact with contaminated surfaces. Requires gown and gloves, dedicated equipment when possible, private room preferred.

• Patient D: Airborne AND contact precautions. Varicella (chickenpox) is transmitted both via airborne route and through contact with vesicular fluid. Negative-pressure room, N95 respirator, gown and gloves. If you're not immune (no vaccine or prior infection), you should not care for this patient.

💡 Key Takeaway: Many diseases require more than one type of transmission-based precaution. Always check facility infection control guidelines.

Example 2: Preventing Falls in a High-Risk Patient

Scenario: Mrs. Chen, 78 years old, was admitted with pneumonia. She is on IV antibiotics. Her medications include furosemide (diuretic), oxycodone PRN for pain, and lorazepam for anxiety. She has a history of one fall at home last month. She is alert but occasionally confused at night. Her Morse Fall Scale score is 60 (high risk, >45 = high risk).

What interventions should you implement?

Comprehensive Fall Prevention Plan:

1. Environmental modifications:

   • Bed in lowest position with wheels locked
   • Call light within reach, teach how to use
   • Non-skid socks on feet
   • Clear path from bed to bathroom
   • Night light in bathroom
   • Remove clutter, unnecessary furniture
   • Place bedside commode if bathroom distance is risky

2. Medication considerations:

   • Furosemide increases urination → frequent toileting needs → fall risk
   • Oxycodone causes sedation and dizziness
   • Lorazepam impairs balance and cognition
   • Schedule toileting before administering these medications
   • Discuss with provider: Can any be discontinued or doses reduced?

3. Mobility and assistance:

   • Assess mobility with physical therapy
   • Ambulate with assistance (never alone)
   • Use gait belt during ambulation
   • Keep walker within reach
   • Sit on edge of bed before standing (prevent orthostatic hypotension)

4. Monitoring:

   • Hourly rounding with "4 P's" (Pain, Potty, Position, Possessions)
   • Bed alarm activated
   • Place patient near nurses' station for closer observation
   • Yellow armband and door sign indicating fall risk
   • Orient to room, especially at night when confusion worsens

5. Communication:

   • Educate patient and family about fall risk
   • Instruct to call for help before getting up
   • Encourage family to stay if possible (sitter)

❌ What NOT to do: Do NOT apply restraints. This would likely increase Mrs. Chen's confusion and agitation, increasing fall risk when she inevitably tries to get out of bed.

Example 3: Responding to a Hazardous Spill

Scenario: You are walking down the hallway when you notice a large puddle of clear liquid with a strong chemical smell near the housekeeping supply closet. Two visitors are approaching the area from the opposite direction.

Immediate Actions:

1. Alert and protect:

   • Immediately tell visitors to stop and use alternate route
   • Ask a colleague to block the area with wet floor signs or furniture
   • Do NOT attempt to identify the substance by smelling it closely

2. Assess the situation:

   • Is anyone injured or exposed?
   • How large is the spill? (This appears large—more than you can handle)
   • Are there patients in adjacent rooms who need protection?

3. Activate emergency response:

   • Call for hazmat team (facilities/environmental services)
   • Notify charge nurse and supervisor
   • If airborne fumes, consider evacuating nearby patient rooms

4. Secure the area:

   • Close doors to adjacent rooms if fumes are strong
   • Post "Do Not Enter" signs
   • Keep unauthorized personnel away
   • Identify source if possible (for hazmat team)

5. Document and follow up:

   • Complete incident report
   • Document: time discovered, location, approximate size, actions taken, who responded
   • If anyone was exposed, ensure they seek medical evaluation
   • Review what chemical was involved (from SDS) to learn for future

If YOU were exposed:

• For skin contact: Flush with copious water for at least 15 minutes, remove contaminated clothing
• For eye contact: Flush at eyewash station for at least 15 minutes
• For inhalation: Move to fresh air immediately
• Always seek medical evaluation after chemical exposure

Example 4: Proper Sterile Technique for Central Line Dressing Change

Scenario: You need to change the dressing on a patient's central venous catheter (CVC). This requires sterile technique to prevent central line-associated bloodstream infection (CLABSI).

Step-by-Step Sterile Procedure:

1. Preparation:

   • Gather supplies: sterile gloves, mask, sterile dressing kit, chlorhexidine antiseptic, new securement device, date label
   • Explain procedure to patient
   • Position patient comfortably (semi-Fowler's if tolerated)
   • Perform hand hygiene

2. Create sterile field:

   • Apply mask (you AND patient—or have patient turn head away)
   • Open sterile dressing kit, creating sterile field
   • Add additional sterile supplies to field without contaminating
   • Remember: 1-inch border is not sterile; anything below waist is contaminated

3. Remove old dressing:

   • Don clean gloves
   • Remove old dressing carefully (stabilize catheter with non-dominant hand)
   • Discard gloves, perform hand hygiene
   • Inspect site for redness, swelling, drainage (signs of infection)

4. Clean the site:

   • Don sterile gloves
   • Use chlorhexidine swabstick (or per facility protocol)
   • Clean in back-and-forth motion or circular pattern starting at insertion site, working outward
   • Allow to dry completely (30 seconds minimum)—chlorhexidine needs drying time for full antimicrobial effect

5. Apply new dressing:

   • Apply new securement device per facility protocol
   • Apply transparent semi-permeable dressing, ensuring insertion site is visible
   • Label with date, time, and your initials
   • Coil and secure catheter to prevent pulling

6. Documentation:

   • Date/time of dressing change
   • Site assessment (intact, no redness/swelling/drainage)
   • Patient tolerance
   • Type of dressing applied

⚠️ If contamination occurs at any point:

• Stop immediately
• Discard contaminated supplies
• Start over with new sterile supplies
• Never compromise sterility to save time or supplies—CLABSI can be fatal

Common Mistakes and How to Avoid Them ⚠️

Mistake 1: Assuming Hand Sanitizer is Always Sufficient

❌ Error: Using alcohol-based hand rub (ABHR) after caring for a patient with C. difficile.

✅ Correction: C. difficile produces spores that are resistant to alcohol. You MUST wash hands with soap and water for at least 20 seconds. The mechanical action of washing removes spores that alcohol cannot kill.

Rule: When in doubt, soap and water is always acceptable. ABHR is convenient but has limitations.

Mistake 2: Donning PPE in the Wrong Order

❌ Error: Putting on gloves before the gown, or putting on the mask last.

✅ Correction: Proper sequence is: Hand hygiene → Gown → Mask/respirator → Goggles → Gloves (over gown cuffs). This ensures maximum protection and easier removal without contamination.

Why it matters: Gloves over gown cuffs create a sealed barrier. If gown goes over gloves, contaminated material can get on your wrists.

Mistake 3: Tying Restraints to Bed Rails

❌ Error: Securing restraints to the side rails "because it's convenient."

✅ Correction: Always secure restraints to the bed frame, not the rails. If rails are lowered while restraints are attached to them, the patient could be injured (strangled, arm pulled out of socket, etc.).

Additional safety: Use quick-release knots that can be rapidly untied in an emergency.

Mistake 4: "Borrowing" Equipment from Isolation Rooms

❌ Error: Taking a blood pressure cuff from a contact precautions room to use on another patient because you can't find one.

✅ Correction: Equipment in isolation rooms should be dedicated to that patient or properly disinfected before use on others. Taking contaminated equipment out of the room defeats the purpose of isolation and spreads pathogens.

Solution: If absolutely necessary to share equipment, thoroughly disinfect per facility protocol before and after each use.

Mistake 5: Recapping Needles "Just This Once"

❌ Error: "I'll be really careful" while recapping a needle after drawing blood.

✅ Correction: NEVER recap needles. The CDC estimates that one-third of all needlestick injuries occur during or after recapping. If a needle absolutely must be recapped (rare circumstances), use the one-handed "scoop" technique, not two hands.

Better solution: Use safety-engineered devices that don't require recapping. Dispose immediately in sharps container.

Mistake 6: Leaving Bed in High Position

❌ Error: Leaving the bed raised after completing a procedure because it's easier on your back.

✅ Correction: Always return bed to lowest position before leaving the room. Falls from high beds cause more serious injuries. Your back comfort doesn't outweigh patient safety.

Use proper body mechanics instead: Raise the bed while you work, lower it when done. This protects both you and the patient.

Mistake 7: Confusing Droplet and Airborne Precautions

❌ Error: Wearing only a surgical mask when caring for a patient with active tuberculosis.

✅ Correction: TB requires airborne precautions with N95 respirator (or PAPR if not fit-tested), not just a surgical mask. Surgical masks filter droplets but not tiny airborne particles.

Memory aid: If the pathogen can travel across a room on air currents, it's airborne (TB, measles, chickenpox). If it drops to the ground within 6 feet, it's droplet (influenza, pertussis).

Key Takeaways: Your Safety and Infection Control Checklist 📋

Further Study 📚

Deepen your knowledge with these authoritative resources:

1. CDC Healthcare Infection Control Practices Advisory Committee (HICPAC) - https://www.cdc.gov/hicpac/index.html - Comprehensive guidelines on isolation precautions, hand hygiene, and prevention of healthcare-associated infections

2. The Joint Commission National Patient Safety Goals - https://www.jointcommission.org/standards/national-patient-safety-goals/ - Current safety priorities including fall prevention, alarm management, and infection prevention

3. OSHA Bloodborne Pathogens Standard - https://www.osha.gov/laws-regs/regulations/standardnumber/1910/1910.1030 - Legal requirements for handling sharps, bloodborne pathogen exposure, and post-exposure protocols

---

You now have a solid foundation in safety and infection control principles essential for the NCLEX-RN exam and safe clinical practice. Remember: safety is not just a checklist—it's a mindset. Every action you take as a nurse should prioritize patient and healthcare worker safety. In the next lesson, we'll explore Health Promotion and Maintenance, building on these foundational safety principles! 🎯