The Quality Improvement Team is putting a ‘Fall Risk’ sign on patient doors, providing non-skid socks, conducting frequent rounds of patient rooms, and using color-coded wristbands.
Which of the following actions will apply?

Choice A rationale
Loosening the restraints and assessing the patient’s skin is important, but it should be done as part of a regular assessment and not as the first action. The nurse should first document the findings to ensure accurate and timely communication of the patient’s condition.
Choice B rationale
Documenting the findings in the patient’s chart is the correct action. Accurate documentation is essential for communicating the patient’s condition and any interventions performed. It ensures continuity of care and provides a legal record of the patient’s status and the care provided.
Choice C rationale
Continuing to monitor the patient without making any changes is not appropriate. The nurse should assess the patient’s condition and document the findings to ensure that any necessary interventions are performed promptly.
Choice D rationale
Applying ice packs to reduce swelling is not appropriate in this context. The nurse should first document the findings and then assess the need for any interventions based on the patient’s condition.

Choice A rationale
Notifying the surgeon and clarifying the discrepancy before proceeding is crucial to ensure patient safety. The time-out procedure is designed to prevent wrong-site, wrong-procedure, and wrong-person surgeries. Any discrepancy must be resolved to avoid potential harm to the patient.
Choice B rationale
Proceeding with the planned procedure as written without addressing the discrepancy can lead to serious errors, such as performing surgery on the wrong site or patient. This action is not aligned with the safety protocols established by the Joint Commission.
Choice C rationale
Discussing the discrepancy with the patient after the surgery does not prevent the error from occurring. The purpose of the time-out procedure is to catch and correct any discrepancies before the surgery begins.
Choice D rationale
Ignoring the discrepancy as it is not significant undermines the entire purpose of the time-out procedure, which is to ensure all details are correct before proceeding with surgery. Even seemingly minor discrepancies can lead to major errors.