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Background: This tool contains a form for reporting environmental hazards when they are detected. Whereas the inspection checklist (Tool 3C, "Tool Covering Environmental Safety at the Bedside") is for regular, systematic review for fall hazards, this form is for hazards detected incidentally during usual care.
Reference: Falls prevention strategies in health care settings. Plymouth Meeting, PA: ECRI Institute; 2006. Hazard Report Form 13: 248. Reprinted with permission.
How to use this tool: Use this form whenever an environmental hazard is detected. You may need to change the people to whom the hazard is reported based on your local organizational setup. Any hospital employee who enters patient rooms can use this form.
Hazard Report Form
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To: Nurse Manager Equipment or Condition Presenting Hazard: _________________________________________ Location of Hazard: _______________________________________________________________ Date Hazard Reported: _____________________________________________________________ Hazard Reported by (your name): __________________________________________________ Corrective Action Taken (describe what you did to eliminate the hazard): __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ Work Order Initiated (describe what still needs to be done to eliminate the hazard): __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ Work Order Completed on: _________________________________________________________ Work Order Completed by: _________________________________________________________ Action Taken to Eliminate Future Occurrences: __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ Hazard Reported at: ______________________________________________________________ Staff Meeting (date): ______________________________________________________________ Shift Reports (date): ______________________________________________________________ Posting on Bulletin Boards (date): __________________________________________________ |
Copies of this form must be forwarded to the Risk Manager.
Reprinted with permission. ©2006, ECRI Institute, 5200 Butler Pike, Plymouth Meeting, PA 19462, www.ecri.org .
