Chapter Two

A sample risk assessment form.

Risk Assessments for Safety and Hazardous Materials

Figure 2-1.
Environmental Tour Checklist
Environmental Environmental Health & Safety Issue: Observation/ Location Room Responsible
Health & Safety Comments: Party
Category

Electrical & Electrical boxes missing or damaged

Equipment Extension cords used as permanent
wiring
Equipment located poorly
Cords located near a water source
Exposed wires
Power cords need to be rerouted
away from sink, water or chemicals
Broken equipment not properly
tagged or labeled
Non-patient care equipment
not properly functioning/guarded
Non-patient care equipment
inspection tag/sticker is outdated
Patient care equipment is not
functional/needs repair
Patient care equipment inspection
sticker/tag outdated
Critical equipment not plugged
into red outlets

Housekeeping Area not clean

Chute room doors are propped open
Microwave needs to be cleaned
Housekeeping carts need repair
Area not orderly
Refrigerator needs to be cleaned
Improper storage on housekeeping cart
Improper storage of chemicals
Improper storage in janitors’ closet
Keys left in janitors closet
Area not clean

continued

23
Environment of Care® Risk Assessment
A sample risk assessment form.

Figure 2-1.
Environmental Tour Checklist (continued)

Environmental Environmental Health & Safety Issue: Observation/ Location Room Responsible
Health & Safety Comments: Party
Category

Fire Hazards Fire exits obstructed

Fire extinguisher inspection tag outdated
Pull stations obstructed
Stairwells obstructed
Electrical boxes obstructed
Storage within 18 inches of the ceiling
Combustibles near a heat source
Aisles and passage ways obstructed
Fire extinguishers obstructed, missing, or
mounted too high
Doors propped, wedged, taped, or tied open
Items located in front of/on top of
flammable cabinet
Excessive amounts of combustibles stored
Heat producing equipment located poorly
Exit signs missing/obstructed
Escutcheon plate missing
Inadequate storage of items on the floor
Fire alarm detection impaired
Exit sign not functioning properly
Items stored on convector unit
Items stored in fire hose cabinet
Fire extinguisher obstructed
Decorations not meeting applicable
standards
Obstructedf fire/smoke door
Space heater found
Candles/smoking materials found
Fire doors closing improperly
Paint covering door rating tag
Glazing in door damaged

continued

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 Chapter Two
Risk Assessments for Safety and Hazardous Materials
A sample risk assessment form.

Figure 2-1.
Environmental Tour Checklist (continued)

Environmental Environmental Health & Safety Issue: Observation/ Location Room Responsible
Health & Safety Comments: Party
Category

Engineering Sharps container not hung properly

Sharps container overfull
Med rooms/cabinets not locked
Exhaust hood needs cleaning
Sink/Counter top damage
Wall damage/painting needed
Doors in need of repair
Items not properly installed
Ceiling tiles missing or need repair
Holes in walls, floor, or ceiling
Flammable cabinet needs repair
Shelves/bracketing need repair
Alcohol soap/gel dispensers not installed
Windows broken/cracked
Items need to be replaced
Lighting not functional/needs to be
repaired or replaced

Trips & Falls Cords present tripping hazards

Supplies/equipment stored improperly
Floor covering in unsafe condition

Personal Prot. PPE missing/improperly used or stored

Equipment (PPE)
“PPE Located Here” signs are missing
Proper isolation techniques not being
performed
Glove holder(s) empty
Gloves stored on top of sharps container
Glove box needs to be replaced
Additional glove boxes needed

continued

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Environment of Care® Risk Assessment
A sample risk assessment form.

Figure 2-1.
Environmental Tour Checklist (continued)

Environmental Environmental Health & Safety Issue: Observation/ Location Room Responsible
Health & Safety Comments: Party
Category

Infection Control Improper storage in refrigerator

Refrigerator logs not up-to-date and/or
inadequately logged
Inadequate temp. for refrigerator
Employee food/drink in patient care areas
Food in refrigerator is not dated (patient only)
Meds unsecured
Dirty linen stored improperly
Clean linen stored improperly
Patient care items stored on the floor
Improper storage of food
Inadequate separation of clean and
soiled supplies
Med prep/food not dated
Med prep equipment not clean
and/or broken
Evidence of standing water
Multi-dose medication found with no date
Isolation stations/carts not
adequately stocked
Improper storage of items
Mattress cover torn/damaged
Expired meds/materials
Uncontrolled sharps/needles
Toys not properly cleaned
Pre-drawn syringes found
Temperature log out of range
Presence of mold found
Meds of discharged patient found
Improper soaking/cleaning of instruments
Improper documentation

Hand Hygiene Hand Hygiene procedures not

properly performed
Paper towels not stored properly
Proper soap missing at sink
Alcohol dispensers empty
continued

26
 Chapter Two
Risk Assessments for Safety and Hazardous Materials
A sample risk assessment form.

Figure 2-1.
Environmental Tour Checklist (continued)

Environmental Environmental Health & Safety Issue: Observation/ Location Room Responsible
Health & Safety Comments: Party
Category

Hazardous Chemicals not labeled

Materials Chemicals stored on the floor
Open chemicals without dates
Compressed gas cylinders
improperly stored
Department does not have up-to-date
chemical inventory
PIMW waste improperly disposed
Red bag being used for regular trash
Improper use of a biohazard bag
PIMW waste container broken/
needs repair
Red bag waste improperly stored
Sharps container needs to be installed
Red bags stored on floor
No lids on red bag trash
Sharps containers unstable
Trash cans need to be replaced
Sharps container full

Signs & Labels Labels used improperly/missing/coming loose

Secondary containers not properly labeled
Proper safety signs missing
Flammable cabinet not properly labeled
Sign/numbers missing or not appropriate
Evacuation routes posted incorrectly/
missing
No stickers on refrigerator
“Wash your Hands” signs not posted in
staff washroom

Security Employees not wearing hospital

issued ID Badge
Keys found in doors
Items/areas not secured
Security system/device not functional

continued

27
Environment of Care® Risk Assessment
A sample risk assessment form.

Figure 2-1.
Environmental Tour Checklist (continued)

Environmental Environmental Health & Safety Issue: Observation/ Location Room Responsible
Health & Safety Comments: Party
Category

Construction Exits obstructed or not inspected daily

Temporary construction areas not smoke
tight & not built of non-combustible material
Additional fire fighting equipment
not available
Storage has not been reduced
Training in alternate fire safety not performed
Safety orientation for contractors not performed
Wires not capped/exposed/
dangerously located
“No smoking” signs posted
Infection Control permit not posted
Staff Knowledge Staff does not have knowledge of
how to obtain an MSDS
Staff does not have knowledge of the
locations of emergency exit routes,
pull stations, fire extinguishers in the area
Staff does not have knowledge of
procedures for an associate injury, needle
stick, or blood or body fluid exposure
Staff does not have knowledge of proper
reporting for SMDA
Staff does not have knowledge of where
to reference Infection Control policies
and procedures
Staff does not have knowledge of where
to reference safety policies and procedures
Staff does not have knowledge of how
to label broken equipment
Staff does not have knowledge of Code Pink
internal or external disasters/emergency
operations plan
Staff does not have knowledge of (Infant/
Child Abduction) procedures
Staff does not have knowledge of controls used
to protect workers from needle stick injuries
Clinical staff does not have knowledge of
how to look up the history of a piece of
medical equipment to identify next date
of scheduled maintenance
Safety Manual is not centrally located
and/or accessible
Staff are observed not following safe
practice/procedures continued

28
 Chapter Two
Risk Assessments for Safety and Hazardous Materials
A sample risk assessment form.

Figure 2-1.
Environmental Tour Checklist (continued)

Environmental Environmental Health & Safety Issue: Observation/ Location Room Responsible
Health & Safety Comments: Party
Category

Flammables Flammables not labeled/labeled incorrectly

Flammables stored improperly
More than one day's supply in secondary
container
Refrigerators with flammables not labeled
Open cans stored under fume hoods >30 days
Propane burning equipment in labs
Chemicals not separated by hazard type
Appropriate spill kits not present
Eyewash station missing/needs to be replaced
Fume hoods have not been tested for face
velocity within 12 months
Velocity of fume hoods is not >100 linear
feet per minute
Holders or mitts for handling hot items
not present
CO2 extinguishers not present
No spill plates used to catch chemicals
Broken glass containers full/not present

Environmental Safety rails need covering

Concerns
Objects can be used as weapons

Breakaway hardware needed

Plastic draws on curtains need to be

removed

Non-glass partitions needed

Vents need to be covered

Hinges present hazard

Engineering controls needed

Tamper-proof screws needed

Electrical outlets need to be covered

Sharps edges present

continued

29
Environment of Care® Risk Assessment
A sample risk assessment form.

Figure 2-1.
Environmental Tour Checklist (continued)

Environmental Environmental Health & Safety Issue: Observation/ Location Room Responsible
Health & Safety Comments: Party
Category

Clinical Issues Medication/Crash carts not properly

working/secured
Emergency medications not secured
Code/Crash carts not properly logged
Narcotics not controlled at all times
Patient information not secured

Other/
Miscellaneous

Notes/Follow-Up

This standardized form is used to help conduct the environmental tour process and ensure that consistent data are collected from all departments.
Source: Loyola University Medical Center, Maywood, IL.

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