Safety incident Report

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

• Select date

  Date

• Location

  Select Medical Center Restorative Care Pelham Hospital Medical Group of Carolina's PELHAM MOB SMC POB

  • Medical Center
  • Restorative Care
  • Pelham Hospital
  • Medical Group of Carolina's
  • PELHAM MOB
  • SMC POB

• Safety Officer

  Jeff Straub

  Doug Neubauer

  Mike Ruiz

  Kim Ross

  Leigh Price

• Status /Condition<br>

  Deferred <24h

  Emergency

  Routine >24h

Physical Environment

• Area Type

  Common Area

  Non-Clinical

  Patient Care / Clinical

• Direct Contact

• Phone #

• Department Manager

• Division VP

• Add media

  Media

Assessment

• Type of Incident

  Life Safety

  Employee Exposure

  Air Quality

  Hazardous Materials

  Unsafe Conditions

• Sub-Type

  Select Combustible Fire A Chemical Fire B Electrical Fire C Fire Load Egress IAQ- Odor/Smells IAQ - Fungal HAZMAT-HD HAZRX HAZMAT-CD Cytotoxin HAZMAT-WAG HAZMAT-LAB CHEM HAZMAT- PETRO EE-Injection EE-Inhalation ERGONOMICS Slip Trip Falls LOTO

  • Combustible Fire A
  • Chemical Fire B
  • Electrical Fire C
  • Fire Load
  • Egress
  • IAQ- Odor/Smells
  • IAQ - Fungal
  • HAZMAT-HD HAZRX
  • HAZMAT-CD Cytotoxin
  • HAZMAT-WAG
  • HAZMAT-LAB CHEM
  • HAZMAT- PETRO
  • EE-Injection
  • EE-Inhalation
  • ERGONOMICS
  • Slip Trip Falls
  • LOTO

• Description of Incident

• IAQ Required

• AIR QUALITY

  Outside

  Sample Area

  Comparison

• Add media

  Media

• Area

• 0.3

• 0.5

• 1.0

• 2.0

• 5.0

• Temperature

• Humidity

• Oxygen %

• Carbon Monoxide

• Hydrogen Sulfide H2S

• Lower Exposure Limit (LEL)

Impact Analysis

• Add media

  Media

• Impact

  Select Business Human Property

  • Business
  • Human
  • Property

• Estimate Cost

  none

  less than $ 1000

  greater than 1000

  greater than 5000

• Safety Actions

Response

• Add media

  Media

• Internal

  Select Safety Facilities Security HERT Guest Services Nursing Supervisor ADMIN Central Transport Volunteer Services Patient Safety Risk Management Code Team Trauma Team

  • Safety
  • Facilities
  • Security
  • HERT
  • Guest Services
  • Nursing Supervisor
  • ADMIN
  • Central Transport
  • Volunteer Services
  • Patient Safety
  • Risk Management
  • Code Team
  • Trauma Team

• External

  Select SBURG CO EM DHEC PUBLIC HEALTH Sheriffs Office SBURGB PUBLIC SAFETY SBURG HAZMAT 43 CIVIL SUPPORT TEAM SPBURG CERT MED RESERVE CORPS

  • SBURG CO EM
  • DHEC PUBLIC HEALTH
  • Sheriffs Office
  • SBURGB PUBLIC SAFETY
  • SBURG HAZMAT
  • 43 CIVIL SUPPORT TEAM
  • SPBURG CERT
  • MED RESERVE CORPS

• 3rd Party Associate

• RESPONSE ACTIVITIES

Recovery

• Add media

  Media

• Follow up required?

  Yes

  No

• Regulatory Reference

  OSHA

  EPA

  DHEC

  DHS

• Forward to

  Select Administration Safety EHS COMMITTEE Facilities Infection Prevention Risk Management Public Relations Nursing Security Switchboard

  • Administration
  • Safety
  • EHS COMMITTEE
  • Facilities
  • Infection Prevention
  • Risk Management
  • Public Relations
  • Nursing
  • Security
  • Switchboard

• Comments

Corrective Action Plan

• Date completed

  Date

• Safety Officer Signature

  Sign