🛡️ S · Safety and protection

statements

actual

risk

urgent

Recommended assessment — CarePath tool: CP-SAFE Safety & Falls Score (interactive scoring) · Validated scales: Morse Fall Scale

🩺 Open CP-SAFE ⬇ Group handbook (PDF)⬇ Blank CP-SAFE form

Code	Problem statement	Type	Description	First 3 actions
S1	Likely to fall	Risk	Weakness, medicine, poor balance, or hazards raise the chance of a fall.	Assess fall risk · Keep the bed low with the call bell in reach · Non-slip shoes
S2	Likely to catch an infection	Risk	Wounds, lines, weak defenses, or exposure raise the chance of infection.	Wash hands · Use clean technique for dressings and lines · Monitor temperature
S3	Likely to get hurt	Risk	The person's condition or surroundings raise the chance of accidental harm.	Remove hazards · Supervise · Meet needs early
S4	Broken or damaged skin	Actual	Skin is cut, torn, blistered, or broken down.	Assess skin daily · Clean and dress as ordered · Protect from friction and moisture
S5	Likely to develop pressure sores	Risk	Staying in one position, moisture, or poor nutrition raise the chance of skin breakdown over bony areas.	Turn every 2 hours or per plan · Check skin · Use a pressure-relieving mattress
S6	Likely to bleed easily	Risk	Blood-thinning medicine, low platelets, or illness raise the chance of bleeding.	Check blood tests (INR) as ordered and report values above target · Check with the prescriber before each warfarin dose while the INR is above target; give at the same time each day as ordered · Use a soft toothbrush and electric razor
S7	Body temperature too high or too low	Actual ⚠ URGENT	Body temperature is outside the safe range because of illness, surroundings, or medicine.	Check temperature · Add or remove layers · Give fluids
S8	Likely to inhale food or fluid	Risk	Weak swallowing or reduced alertness raise the chance of food or fluid entering the lungs.	Sit fully upright to eat · Supervise meals · Follow swallow advice
S9	Slow wound or surgical healing	Risk	Poor nutrition, infection, or illness may slow healing.	Check the wound every shift · Support nutrition · Control blood sugar
S10	Reaction to medicine or allergen	Risk ⚠ URGENT	The person may react to a medicine, food, latex, or other trigger.	Check allergies before every drug · Use an allergy band · Observe after new medicines
S11	Likely to develop blood clots	Risk	Limited movement, surgery, or illness raise the chance of clots in the veins.	Give clot prevention as ordered · Encourage early movement and fluids as allowed · Check both legs each shift for swelling, pain, redness or warmth
S12	Likely to bleed heavily after surgery	Risk ⚠ URGENT	The surgical site may bleed more than expected.	Check dressings, drain output and vital signs at ordered times · Keep dressings intact and mark any leaking area · Report quickly rising drain output, bright blood, rising pulse, falling blood pressure or paleness at once
S13	Wrong medicine or dose	Risk	Errors in drug, dose, time, route, or patient may cause harm.	Check the patient's name band and ask the patient to state their name before every medicine · Check drug, dose, time, route and allergies against the order · Mark similar-name patients with an alert
S14	Harm from restraints	Risk	Physical or chemical restraints can cause injury, distress, and loss of dignity.	Use the least restrictive option · Follow policy · Check restraints often
S15	Likely to wander or get lost	Risk	Confusion or memory loss may lead the person to leave a safe place.	Use an ID band · Place near the nursing station · Distract and redirect
S16	Burn or scald risk	Risk	Hot water, heat packs, or equipment may burn skin, especially where feeling is reduced.	Test water temperature · Avoid heat packs on numb skin · Supervise baths
S17	Choking	Risk ⚠ URGENT	Food or objects may block the airway.	Cut food small and serve soft foods if needed · Sit upright and supervise every meal · Remind to eat slowly without talking
S18	Poisoning risk	Risk ⚠ URGENT	Access to harmful substances or medicine overdose raises the chance of poisoning.	Teach parents to lock medicines and chemicals away, out of sight and reach · Use child-safe lids and keep medicines in original labelled containers · Give the poison-control number and put it near the phone
S19	Unsafe home	Risk	Hazards such as clutter, poor lighting, or loose rugs raise the chance of injury.	Do a home safety check · Improve lighting · Clear clutter and secure loose items
S20	Abuse or violence exposure	Risk	The person may be exposed to harm from others or be recovering from it.	Ask privately and kindly · Ensure safety · Document facts
S21	Likely to harm others	Risk	Anger, confusion, or illness may lead to violence toward other people.	Stay calm · Keep a safe distance · Give space
S22	Staff exposure to needles or body fluids (workplace safety)	Risk	Healthcare workers may be exposed to blood-borne infection through sharps or splashes.	Use safety devices · Keep a sharps bin at the point of use · Never recap
S23	Nerve or limb damage from positioning	Risk	Pressure or poor positioning may damage nerves or reduce blood flow to a limb.	Pad and support limbs · Avoid pressure · Reposition
S24	Likely to spread infection to others	Risk	An infectious person may pass germs to other patients, staff, or family.	Use isolation as needed · Do hand hygiene · Wear masks and gloves
S25	Eye damage in unconscious patients	Risk	Eyes that do not blink or close may dry out or be scratched.	Clean eyes · Use lubricant · Close eyes gently or cover as ordered
S26	Injury during seizure	Risk ⚠ URGENT	Falls, tongue bites, or a blocked airway may occur during a seizure.	Give anti-seizure medicine on time and as ordered · Keep the bed low and padded; clear the area · Teach the patient and family seizure first aid

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