Safety EOC Checklist 2020

• Conducted on

  Date

• Prepared by

• Location

  East Lake Facility

  AT Bldg

  Yards

  Westlake Facility

• Detailed Location

  Select AT Bldg/TX Mall GPU Food Service West Lake / Pod H 3N1 APU GPU Pod HMH 1S1 FSU GPU Pod B Food Service East Lake-both levels 1N1 APU GPU Pod D 2N1 APU FSU/APU/AT Bldg Yard Spaces/Sidewalks 2S1 FSU GPU Pod E Dental Office 0N3 / Psychology Area 2N3 FSU GPU Lab Pharmacy GPU OT and Rehab Areas 3S1 FSU HR / IT / Safety Offices / Rehab Offices / ETRU Security / PERT /Social Work / FSU Psychology Area / Med Staff Office Medical Records / SB / Accounting-includes patient funds /Admin / CNO / Educational Services 0N3 Offices  / Central Supply / Housekeeping / Basement Corridor / QM GPU Common areas

  • AT Bldg/TX Mall
  • GPU Food Service West Lake / Pod H
  • 3N1 APU
  • GPU Pod HMH
  • 1S1 FSU
  • GPU Pod B
  • Food Service East Lake-both levels
  • 1N1 APU
  • GPU Pod D
  • 2N1 APU
  • FSU/APU/AT Bldg Yard Spaces/Sidewalks
  • 2S1 FSU
  • GPU Pod E
  • Dental Office 0N3 / Psychology Area
  • 2N3 FSU
  • GPU Lab
  • Pharmacy
  • GPU OT and Rehab Areas
  • 3S1 FSU
  • HR / IT / Safety Offices / Rehab Offices / ETRU
  • Security / PERT /Social Work / FSU Psychology Area / Med Staff Office
  • Medical Records / SB / Accounting-includes patient funds /Admin / CNO /
  • Educational Services
  • 0N3 Offices  / Central Supply / Housekeeping / Basement Corridor / QM
  • GPU Common areas

• Safety 1. In controlled building areas where friable asbestos containing materials exist, appropriate warning labels and signage is present (e.g. ceiling spaces, boiler rooms, tunnels, crawl spaces, etc.)?

  Yes

  No

  N/A

• What is the likelihood to harm a patient / staff / Visitor?

  Select High: Could directly lead to harm without need for other significant circumstances or failures.--Likely Moderate: Could cause harm directly, but more likely to cause harm as a contributing factor in the presence of special circumstances or additional failures.--Possible Low: Undermines safety/quality or contributes to an unsafe environment, but very unlikely to directly contribute to harm.--Rare

  • High: Could directly lead to harm without need for other significant circumstances or failures.--Likely
  • Moderate: Could cause harm directly, but more likely to cause harm as a contributing factor in the presence of special circumstances or additional failures.--Possible
  • Low: Undermines safety/quality or contributes to an unsafe environment, but very unlikely to directly contribute to harm.--Rare

• Is the problem…

  Select Widespread: issue is “pervasive at the organization” --Process failure/systemic failure --Majority of patients are/could be impacted Pattern: issue has potential to “impact more than a limited number of patients impacted” -- Process variation -- > or = 3 but less than 50% patients impacted Limited: issue is a “unique occurrence” -- Outlier -- Not representative of routine/regular practice

  • Widespread: issue is “pervasive at the organization” --Process failure/systemic failure --Majority of patients are/could be impacted
  • Pattern: issue has potential to “impact more than a limited number of patients impacted” -- Process variation -- > or = 3 but less than 50% patients impacted
  • Limited: issue is a “unique occurrence” -- Outlier -- Not representative of routine/regular practice

• Safety 2. Areas are clean and free of offensive odors?

  Yes

  No

  N/A

• What is the likelihood to harm a patient / staff / Visitor?

  Select High: Could directly lead to harm without need for other significant circumstances or failures.--Likely Moderate: Could cause harm directly, but more likely to cause harm as a contributing factor in the presence of special circumstances or additional failures.--Possible Low: Undermines safety/quality or contributes to an unsafe environment, but very unlikely to directly contribute to harm.--Rare

  • High: Could directly lead to harm without need for other significant circumstances or failures.--Likely
  • Moderate: Could cause harm directly, but more likely to cause harm as a contributing factor in the presence of special circumstances or additional failures.--Possible
  • Low: Undermines safety/quality or contributes to an unsafe environment, but very unlikely to directly contribute to harm.--Rare

• Is the problem…

  Select Widespread: issue is “pervasive at the organization” --Process failure/systemic failure --Majority of patients are/could be impacted Pattern: issue has potential to “impact more than a limited number of patients impacted” -- Process variation -- > or = 3 but less than 50% patients impacted Limited: issue is a “unique occurrence” -- Outlier -- Not representative of routine/regular practice

  • Widespread: issue is “pervasive at the organization” --Process failure/systemic failure --Majority of patients are/could be impacted
  • Pattern: issue has potential to “impact more than a limited number of patients impacted” -- Process variation -- > or = 3 but less than 50% patients impacted
  • Limited: issue is a “unique occurrence” -- Outlier -- Not representative of routine/regular practice

• Safety 3. Emergency access is provided for all locked and occupied spaces? (e.g. patient bathrooms, seclusion rooms, etc.)

  Yes

  No

  N/A

• What is the likelihood to harm a patient / staff / Visitor?

  Select High: Could directly lead to harm without need for other significant circumstances or failures.--Likely Moderate: Could cause harm directly, but more likely to cause harm as a contributing factor in the presence of special circumstances or additional failures.--Possible Low: Undermines safety/quality or contributes to an unsafe environment, but very unlikely to directly contribute to harm.--Rare

  • High: Could directly lead to harm without need for other significant circumstances or failures.--Likely
  • Moderate: Could cause harm directly, but more likely to cause harm as a contributing factor in the presence of special circumstances or additional failures.--Possible
  • Low: Undermines safety/quality or contributes to an unsafe environment, but very unlikely to directly contribute to harm.--Rare

• Is the problem…

  Select Widespread: issue is “pervasive at the organization” --Process failure/systemic failure --Majority of patients are/could be impacted Pattern: issue has potential to “impact more than a limited number of patients impacted” -- Process variation -- > or = 3 but less than 50% patients impacted Limited: issue is a “unique occurrence” -- Outlier -- Not representative of routine/regular practice

  • Widespread: issue is “pervasive at the organization” --Process failure/systemic failure --Majority of patients are/could be impacted
  • Pattern: issue has potential to “impact more than a limited number of patients impacted” -- Process variation -- > or = 3 but less than 50% patients impacted
  • Limited: issue is a “unique occurrence” -- Outlier -- Not representative of routine/regular practice

• Safety 4. Emergency eyewash and shower equipment is accessible, and inspected/tested monthly?

  Yes

  No

  N/A

• What is the likelihood to harm a patient / staff / Visitor?

  Select High: Could directly lead to harm without need for other significant circumstances or failures.--Likely Moderate: Could cause harm directly, but more likely to cause harm as a contributing factor in the presence of special circumstances or additional failures.--Possible Low: Undermines safety/quality or contributes to an unsafe environment, but very unlikely to directly contribute to harm.--Rare

  • High: Could directly lead to harm without need for other significant circumstances or failures.--Likely
  • Moderate: Could cause harm directly, but more likely to cause harm as a contributing factor in the presence of special circumstances or additional failures.--Possible
  • Low: Undermines safety/quality or contributes to an unsafe environment, but very unlikely to directly contribute to harm.--Rare

• Is the problem…

  Select Widespread: issue is “pervasive at the organization” --Process failure/systemic failure --Majority of patients are/could be impacted Pattern: issue has potential to “impact more than a limited number of patients impacted” -- Process variation -- > or = 3 but less than 50% patients impacted Limited: issue is a “unique occurrence” -- Outlier -- Not representative of routine/regular practice

  • Widespread: issue is “pervasive at the organization” --Process failure/systemic failure --Majority of patients are/could be impacted
  • Pattern: issue has potential to “impact more than a limited number of patients impacted” -- Process variation -- > or = 3 but less than 50% patients impacted
  • Limited: issue is a “unique occurrence” -- Outlier -- Not representative of routine/regular practice

• Safety 5. Area staff are familiar with the location and use of emergency eyewash and shower equipment?

  Yes

  No

  N/A

• What is the likelihood to harm a patient / staff / Visitor?

  Select High: Could directly lead to harm without need for other significant circumstances or failures.--Likely Moderate: Could cause harm directly, but more likely to cause harm as a contributing factor in the presence of special circumstances or additional failures.--Possible Low: Undermines safety/quality or contributes to an unsafe environment, but very unlikely to directly contribute to harm.--Rare

  • High: Could directly lead to harm without need for other significant circumstances or failures.--Likely
  • Moderate: Could cause harm directly, but more likely to cause harm as a contributing factor in the presence of special circumstances or additional failures.--Possible
  • Low: Undermines safety/quality or contributes to an unsafe environment, but very unlikely to directly contribute to harm.--Rare

• Is the problem…

  Select Widespread: issue is “pervasive at the organization” --Process failure/systemic failure --Majority of patients are/could be impacted Pattern: issue has potential to “impact more than a limited number of patients impacted” -- Process variation -- > or = 3 but less than 50% patients impacted Limited: issue is a “unique occurrence” -- Outlier -- Not representative of routine/regular practice

  • Widespread: issue is “pervasive at the organization” --Process failure/systemic failure --Majority of patients are/could be impacted
  • Pattern: issue has potential to “impact more than a limited number of patients impacted” -- Process variation -- > or = 3 but less than 50% patients impacted
  • Limited: issue is a “unique occurrence” -- Outlier -- Not representative of routine/regular practice

• Safety 6. Medical gas cylinders are properly secured when in use, in storage and in transport?

  Yes

  No

  N/A

• What is the likelihood to harm a patient / staff / Visitor?

  Select High: Could directly lead to harm without need for other significant circumstances or failures.--Likely Moderate: Could cause harm directly, but more likely to cause harm as a contributing factor in the presence of special circumstances or additional failures.--Possible Low: Undermines safety/quality or contributes to an unsafe environment, but very unlikely to directly contribute to harm.--Rare

  • High: Could directly lead to harm without need for other significant circumstances or failures.--Likely
  • Moderate: Could cause harm directly, but more likely to cause harm as a contributing factor in the presence of special circumstances or additional failures.--Possible
  • Low: Undermines safety/quality or contributes to an unsafe environment, but very unlikely to directly contribute to harm.--Rare

• Is the problem…

  Select Widespread: issue is “pervasive at the organization” --Process failure/systemic failure --Majority of patients are/could be impacted Pattern: issue has potential to “impact more than a limited number of patients impacted” -- Process variation -- > or = 3 but less than 50% patients impacted Limited: issue is a “unique occurrence” -- Outlier -- Not representative of routine/regular practice

  • Widespread: issue is “pervasive at the organization” --Process failure/systemic failure --Majority of patients are/could be impacted
  • Pattern: issue has potential to “impact more than a limited number of patients impacted” -- Process variation -- > or = 3 but less than 50% patients impacted
  • Limited: issue is a “unique occurrence” -- Outlier -- Not representative of routine/regular practice

• Safety 7. If stored within the same enclosure, empty and partial medical gas cylinders are segregated from full cylinders and are marked to avoid confusion and delay?

  Yes

  No

  N/A

• What is the likelihood to harm a patient / staff / Visitor?

  Select High: Could directly lead to harm without need for other significant circumstances or failures.--Likely Moderate: Could cause harm directly, but more likely to cause harm as a contributing factor in the presence of special circumstances or additional failures.--Possible Low: Undermines safety/quality or contributes to an unsafe environment, but very unlikely to directly contribute to harm.--Rare

  • High: Could directly lead to harm without need for other significant circumstances or failures.--Likely
  • Moderate: Could cause harm directly, but more likely to cause harm as a contributing factor in the presence of special circumstances or additional failures.--Possible
  • Low: Undermines safety/quality or contributes to an unsafe environment, but very unlikely to directly contribute to harm.--Rare

• Is the problem…

  Select Widespread: issue is “pervasive at the organization” --Process failure/systemic failure --Majority of patients are/could be impacted Pattern: issue has potential to “impact more than a limited number of patients impacted” -- Process variation -- > or = 3 but less than 50% patients impacted Limited: issue is a “unique occurrence” -- Outlier -- Not representative of routine/regular practice

  • Widespread: issue is “pervasive at the organization” --Process failure/systemic failure --Majority of patients are/could be impacted
  • Pattern: issue has potential to “impact more than a limited number of patients impacted” -- Process variation -- > or = 3 but less than 50% patients impacted
  • Limited: issue is a “unique occurrence” -- Outlier -- Not representative of routine/regular practice

• Safety 8. Blanket warming cabinet temperatures are maintained at or below 130F, logs are current and actions are documented for failed readings?

  Yes

  No

  N/A

• What is the likelihood to harm a patient / staff / Visitor?

  Select High: Could directly lead to harm without need for other significant circumstances or failures.--Likely Moderate: Could cause harm directly, but more likely to cause harm as a contributing factor in the presence of special circumstances or additional failures.--Possible Low: Undermines safety/quality or contributes to an unsafe environment, but very unlikely to directly contribute to harm.--Rare

  • High: Could directly lead to harm without need for other significant circumstances or failures.--Likely
  • Moderate: Could cause harm directly, but more likely to cause harm as a contributing factor in the presence of special circumstances or additional failures.--Possible
  • Low: Undermines safety/quality or contributes to an unsafe environment, but very unlikely to directly contribute to harm.--Rare

• Is the problem…

  Select Widespread: issue is “pervasive at the organization” --Process failure/systemic failure --Majority of patients are/could be impacted Pattern: issue has potential to “impact more than a limited number of patients impacted” -- Process variation -- > or = 3 but less than 50% patients impacted Limited: issue is a “unique occurrence” -- Outlier -- Not representative of routine/regular practice

  • Widespread: issue is “pervasive at the organization” --Process failure/systemic failure --Majority of patients are/could be impacted
  • Pattern: issue has potential to “impact more than a limited number of patients impacted” -- Process variation -- > or = 3 but less than 50% patients impacted
  • Limited: issue is a “unique occurrence” -- Outlier -- Not representative of routine/regular practice

• Safety 9. Practices are in place to protect patient privacy and confidentiality?

  Yes

  No

  N/A

• What is the likelihood to harm a patient / staff / Visitor?

  Select High: Could directly lead to harm without need for other significant circumstances or failures.--Likely Moderate: Could cause harm directly, but more likely to cause harm as a contributing factor in the presence of special circumstances or additional failures.--Possible Low: Undermines safety/quality or contributes to an unsafe environment, but very unlikely to directly contribute to harm.--Rare

  • High: Could directly lead to harm without need for other significant circumstances or failures.--Likely
  • Moderate: Could cause harm directly, but more likely to cause harm as a contributing factor in the presence of special circumstances or additional failures.--Possible
  • Low: Undermines safety/quality or contributes to an unsafe environment, but very unlikely to directly contribute to harm.--Rare

• Is the problem…

  Select Widespread: issue is “pervasive at the organization” --Process failure/systemic failure --Majority of patients are/could be impacted Pattern: issue has potential to “impact more than a limited number of patients impacted” -- Process variation -- > or = 3 but less than 50% patients impacted Limited: issue is a “unique occurrence” -- Outlier -- Not representative of routine/regular practice

  • Widespread: issue is “pervasive at the organization” --Process failure/systemic failure --Majority of patients are/could be impacted
  • Pattern: issue has potential to “impact more than a limited number of patients impacted” -- Process variation -- > or = 3 but less than 50% patients impacted
  • Limited: issue is a “unique occurrence” -- Outlier -- Not representative of routine/regular practice

• Safety 10. Smoking:▪ Facility's smoking policy is effectively enforced▪Appropriate ""NO SMOKING" signage is posted

  Yes

  No

  N/A

• What is the likelihood to harm a patient / staff / Visitor?

  Select High: Could directly lead to harm without need for other significant circumstances or failures.--Likely Moderate: Could cause harm directly, but more likely to cause harm as a contributing factor in the presence of special circumstances or additional failures.--Possible Low: Undermines safety/quality or contributes to an unsafe environment, but very unlikely to directly contribute to harm.--Rare

  • High: Could directly lead to harm without need for other significant circumstances or failures.--Likely
  • Moderate: Could cause harm directly, but more likely to cause harm as a contributing factor in the presence of special circumstances or additional failures.--Possible
  • Low: Undermines safety/quality or contributes to an unsafe environment, but very unlikely to directly contribute to harm.--Rare

• Is the problem…

  Select Widespread: issue is “pervasive at the organization” --Process failure/systemic failure --Majority of patients are/could be impacted Pattern: issue has potential to “impact more than a limited number of patients impacted” -- Process variation -- > or = 3 but less than 50% patients impacted Limited: issue is a “unique occurrence” -- Outlier -- Not representative of routine/regular practice

  • Widespread: issue is “pervasive at the organization” --Process failure/systemic failure --Majority of patients are/could be impacted
  • Pattern: issue has potential to “impact more than a limited number of patients impacted” -- Process variation -- > or = 3 but less than 50% patients impacted
  • Limited: issue is a “unique occurrence” -- Outlier -- Not representative of routine/regular practice

• Safety 11. A minimum of 18" clearance is maintained between fire sprinkler heads and adjacent storage?

  Yes

  No

  N/A

• What is the likelihood to harm a patient / staff / Visitor?

  Select High: Could directly lead to harm without need for other significant circumstances or failures.--Likely Moderate: Could cause harm directly, but more likely to cause harm as a contributing factor in the presence of special circumstances or additional failures.--Possible Low: Undermines safety/quality or contributes to an unsafe environment, but very unlikely to directly contribute to harm.--Rare

  • High: Could directly lead to harm without need for other significant circumstances or failures.--Likely
  • Moderate: Could cause harm directly, but more likely to cause harm as a contributing factor in the presence of special circumstances or additional failures.--Possible
  • Low: Undermines safety/quality or contributes to an unsafe environment, but very unlikely to directly contribute to harm.--Rare

• Is the problem…

  Select Widespread: issue is “pervasive at the organization” --Process failure/systemic failure --Majority of patients are/could be impacted Pattern: issue has potential to “impact more than a limited number of patients impacted” -- Process variation -- > or = 3 but less than 50% patients impacted Limited: issue is a “unique occurrence” -- Outlier -- Not representative of routine/regular practice

  • Widespread: issue is “pervasive at the organization” --Process failure/systemic failure --Majority of patients are/could be impacted
  • Pattern: issue has potential to “impact more than a limited number of patients impacted” -- Process variation -- > or = 3 but less than 50% patients impacted
  • Limited: issue is a “unique occurrence” -- Outlier -- Not representative of routine/regular practice

• Safety 12. Empty patient rooms are not used for the storage of combustible materials?

  Yes

  No

  N/A

• What is the likelihood to harm a patient / staff / Visitor?

  Select High: Could directly lead to harm without need for other significant circumstances or failures.--Likely Moderate: Could cause harm directly, but more likely to cause harm as a contributing factor in the presence of special circumstances or additional failures.--Possible Low: Undermines safety/quality or contributes to an unsafe environment, but very unlikely to directly contribute to harm.--Rare

  • High: Could directly lead to harm without need for other significant circumstances or failures.--Likely
  • Moderate: Could cause harm directly, but more likely to cause harm as a contributing factor in the presence of special circumstances or additional failures.--Possible
  • Low: Undermines safety/quality or contributes to an unsafe environment, but very unlikely to directly contribute to harm.--Rare

• Is the problem…

  Select Widespread: issue is “pervasive at the organization” --Process failure/systemic failure --Majority of patients are/could be impacted Pattern: issue has potential to “impact more than a limited number of patients impacted” -- Process variation -- > or = 3 but less than 50% patients impacted Limited: issue is a “unique occurrence” -- Outlier -- Not representative of routine/regular practice

  • Widespread: issue is “pervasive at the organization” --Process failure/systemic failure --Majority of patients are/could be impacted
  • Pattern: issue has potential to “impact more than a limited number of patients impacted” -- Process variation -- > or = 3 but less than 50% patients impacted
  • Limited: issue is a “unique occurrence” -- Outlier -- Not representative of routine/regular practice

• Safety 13. Nurse-call emergency pull stations comply with the following:▪ Equipped with pull cords that do not pose a ligature risk▪ Pull cords not long than 6

  Yes

  No

  N/A

• What is the likelihood to harm a patient / staff / Visitor?

  Select High: Could directly lead to harm without need for other significant circumstances or failures.--Likely Moderate: Could cause harm directly, but more likely to cause harm as a contributing factor in the presence of special circumstances or additional failures.--Possible Low: Undermines safety/quality or contributes to an unsafe environment, but very unlikely to directly contribute to harm.--Rare

  • High: Could directly lead to harm without need for other significant circumstances or failures.--Likely
  • Moderate: Could cause harm directly, but more likely to cause harm as a contributing factor in the presence of special circumstances or additional failures.--Possible
  • Low: Undermines safety/quality or contributes to an unsafe environment, but very unlikely to directly contribute to harm.--Rare

• Is the problem…

  Select Widespread: issue is “pervasive at the organization” --Process failure/systemic failure --Majority of patients are/could be impacted Pattern: issue has potential to “impact more than a limited number of patients impacted” -- Process variation -- > or = 3 but less than 50% patients impacted Limited: issue is a “unique occurrence” -- Outlier -- Not representative of routine/regular practice

  • Widespread: issue is “pervasive at the organization” --Process failure/systemic failure --Majority of patients are/could be impacted
  • Pattern: issue has potential to “impact more than a limited number of patients impacted” -- Process variation -- > or = 3 but less than 50% patients impacted
  • Limited: issue is a “unique occurrence” -- Outlier -- Not representative of routine/regular practice

• Safety 14. Wall mounted projections into corridors ≥ 6 feet wide:▪ Project no more than 6" into the corridor▪ Are no more than 36" wide ▪ Are installed at least 48" apart▪ Are installed above handrail height

  Yes

  No

  N/A

• What is the likelihood to harm a patient / staff / Visitor?

  Select High: Could directly lead to harm without need for other significant circumstances or failures.--Likely Moderate: Could cause harm directly, but more likely to cause harm as a contributing factor in the presence of special circumstances or additional failures.--Possible Low: Undermines safety/quality or contributes to an unsafe environment, but very unlikely to directly contribute to harm.--Rare

  • High: Could directly lead to harm without need for other significant circumstances or failures.--Likely
  • Moderate: Could cause harm directly, but more likely to cause harm as a contributing factor in the presence of special circumstances or additional failures.--Possible
  • Low: Undermines safety/quality or contributes to an unsafe environment, but very unlikely to directly contribute to harm.--Rare

• Is the problem…

  Select Widespread: issue is “pervasive at the organization” --Process failure/systemic failure --Majority of patients are/could be impacted Pattern: issue has potential to “impact more than a limited number of patients impacted” -- Process variation -- > or = 3 but less than 50% patients impacted Limited: issue is a “unique occurrence” -- Outlier -- Not representative of routine/regular practice

  • Widespread: issue is “pervasive at the organization” --Process failure/systemic failure --Majority of patients are/could be impacted
  • Pattern: issue has potential to “impact more than a limited number of patients impacted” -- Process variation -- > or = 3 but less than 50% patients impacted
  • Limited: issue is a “unique occurrence” -- Outlier -- Not representative of routine/regular practice

• Safety 15. If you are injured at work , what do you do?

  Yes

  No

  N/A

• What is the likelihood to harm a patient / staff / Visitor?

  Select High: Could directly lead to harm without need for other significant circumstances or failures.--Likely Moderate: Could cause harm directly, but more likely to cause harm as a contributing factor in the presence of special circumstances or additional failures.--Possible Low: Undermines safety/quality or contributes to an unsafe environment, but very unlikely to directly contribute to harm.--Rare

  • High: Could directly lead to harm without need for other significant circumstances or failures.--Likely
  • Moderate: Could cause harm directly, but more likely to cause harm as a contributing factor in the presence of special circumstances or additional failures.--Possible
  • Low: Undermines safety/quality or contributes to an unsafe environment, but very unlikely to directly contribute to harm.--Rare

• Is the problem…

  Select Widespread: issue is “pervasive at the organization” --Process failure/systemic failure --Majority of patients are/could be impacted Pattern: issue has potential to “impact more than a limited number of patients impacted” -- Process variation -- > or = 3 but less than 50% patients impacted Limited: issue is a “unique occurrence” -- Outlier -- Not representative of routine/regular practice

  • Widespread: issue is “pervasive at the organization” --Process failure/systemic failure --Majority of patients are/could be impacted
  • Pattern: issue has potential to “impact more than a limited number of patients impacted” -- Process variation -- > or = 3 but less than 50% patients impacted
  • Limited: issue is a “unique occurrence” -- Outlier -- Not representative of routine/regular practice

• Safety 16. Where do you the UOR report and Form 133?

  Yes

  No

  N/A

• What is the likelihood to harm a patient / staff / Visitor?

  Select High: Could directly lead to harm without need for other significant circumstances or failures.--Likely Moderate: Could cause harm directly, but more likely to cause harm as a contributing factor in the presence of special circumstances or additional failures.--Possible Low: Undermines safety/quality or contributes to an unsafe environment, but very unlikely to directly contribute to harm.--Rare

  • High: Could directly lead to harm without need for other significant circumstances or failures.--Likely
  • Moderate: Could cause harm directly, but more likely to cause harm as a contributing factor in the presence of special circumstances or additional failures.--Possible
  • Low: Undermines safety/quality or contributes to an unsafe environment, but very unlikely to directly contribute to harm.--Rare

• Is the problem…

  Select Widespread: issue is “pervasive at the organization” --Process failure/systemic failure --Majority of patients are/could be impacted Pattern: issue has potential to “impact more than a limited number of patients impacted” -- Process variation -- > or = 3 but less than 50% patients impacted Limited: issue is a “unique occurrence” -- Outlier -- Not representative of routine/regular practice

  • Widespread: issue is “pervasive at the organization” --Process failure/systemic failure --Majority of patients are/could be impacted
  • Pattern: issue has potential to “impact more than a limited number of patients impacted” -- Process variation -- > or = 3 but less than 50% patients impacted
  • Limited: issue is a “unique occurrence” -- Outlier -- Not representative of routine/regular practice

General Comments Not Included in the Checklist

• Safety 17. Do you have any additional comments? If so, please add them here.

• Add media

  Media