The nurse is working a weekend evening shift on a medical unit. While the nurse is passing medications, one of the patients, an obese patient who is unsteady on his feet, wants to get out of bed and sit in the bedside chair. The patient has been instructed to ask for help when transferring and there is a bed alarm on the bed. The chair is right next to the bed. The nurse assists the patient into a sitting position on the edge of the bed. The nurse’s cell phone starts to vibrate, indicating a call. The nurse turns away to answer the cell phone, telling the patient to stay right where he is. The patient does not respond. He stands suddenly, reaching for the arm of the chair. The bed alarm sounds. The nurse looks over, moves quickly, and tries to stop the patient. The patient falls to the floor, and so does the nurse. The fall results in a broken hip for the patient and a broken wrist for the nurse.

1.

What CUES (Assessment) should the nurse have assessed to support the patient’s safety?

2.

What HYPOTHESIS (Diagnosis) should the nurse have considered to support the patient’s safety?

3.

What ACTION (Plan and Implement) would have been most effective for the nurse to take to assure the patient’s safety in this situation?

4.

How could the nurse have evaluated the patient’s OUTCOME (Evaluation) to support this patient’s safety?