Information
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ASSESSMENT CONDUCTED BY
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CONDUCTED ON
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TYPE OF CALL
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CITY
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LOCATION OF CALL (Kitchen eg)
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STATION
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Document No.
PLEASE OBSERVE THE WORK ACTIVITIES AND USE THE CHECKLIST BELOW TO DETERMINE/ASSESS IF MEASURES OF CONTROL WERE TAKEN TO ENSURE THE ACTIVITY WAS CONDUCTED SAFELY.
PRIOR TO THE CALL
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Was the call at the beginning, middle or end of the shift?
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Footwear in good condition and safely tied?
ON THE WAY TO THE CALL (if observed)
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Gathered information from dispatch and started their risk assessment?
AT THE SCENE
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Positioned the ambulance to ensure their safe exit and egress?
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Positioned Ambulance to ensure safe unload and load of equipment?
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Assessment of patient
PREPARING FOR THE LIFT OR TRANSFER
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Selected the appropriate equipment taking into consideration the work environment and weight/height of the patient.
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Called for additional help, when dictated by weight/height of patient and circumstances that increase risk.
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Early recognition of need for additional help.
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Call for additional help did not affect patient outcome
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Checked for and removed any hazards on patient or self.
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Discussed and agreed on a plan with persons involved in lift or transfer.
PREPARING FOR THE LIFT OR TRANSFER
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Communicated plan to patient (if conscious)
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Established feedback mechanism with patient.
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Positioned equipment properly (if needed)
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Positioned body properly
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Established firm footing.
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Positioned feet shoulder width apart.
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Established firm power grip on equipment or patient
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Communicated sequence of lift with partner and other agency personnel.
POSITIONING PATIENT ON EQUIPMENT OR MOVING WITH PATIENT
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Turned body with feet and avoided unnecessary twisting when positioning the patient on the equipment.
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Properly secured patient to equipment.
LIFTING OR TRANSFERRING USING WHICH FERNO PRODUCT?
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Which lifting device was used?
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Bent knees?
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Used a pelvic tilt?
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Lifted with legs?
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Exhaled when lifting/pulling?
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Kept load close to body?
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Maintained balance?
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Maintained contact and communication with partner(s)?
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Maintained control of the lift/transfer throughout?
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Lift/transfer was gradual, smooth motion with no jerking?
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Lift/transfer plan was implemented as planned?
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Clear route of access/egress?
LIFTING OR TRANSFERRING USING OTHER THAN PREVIOUS PRODUCT
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Was there a second piece of equipment used to lift or transfer?
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Which lifting device was used?
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Bent knees?
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Used a pelvic tilt?
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Lifted with legs?
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Exhaled when lifting/pulling?
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Kept load close to body?
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Maintained balance?
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Maintained contact and communication with partner(s)?
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Maintained control of the lift/transfer throughout?
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Lift/transfer was gradual, smooth motion with no jerking?
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Lift/transfer plan was implemented as planned?
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Clear route of access/egress?
TRANSFERRING PATIENT TO AMBULANCE
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Patient not wheeled with stretcher in top two positions
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Lift/transfer plan was implemented as planned?
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Patient always attended while on equipment
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Stretcher pushed not pulled
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Ensuring that all belts are securely fastened
PREPARING TO LOAD PATIENT INTO AMBULANCE
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Ensured no tripping hazards.
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Discussed and agreed on a plan with persons involved in lift or transfer.
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Communicated plan to patient (if conscious).
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Established communication mechanism with patient.
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Correctly positioned the equipment the patient was on (if needed).
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Positioned personnel properly.
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Established firm footing.
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Positioned feet shoulder-width apart.
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Established firm power grip on equipment.
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Maintained control of the "Gatch" throughout the lift.
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Ensure safety hook engaged.
UNLOADING PATIENT FROM AMBULANCE
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Ensure sufficient space to unload patient safely.
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Bent knees when lifting/lowering.
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Used a pelvic tilt.
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Kept back straight.
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Lowered/lifted with legs.
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Exhaled when lifting/pulling.
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Kept load close to body.
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Maintained balance.
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Maintained contact and communication with partner(s)?
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Maintained control of the "Gatch" throughout the lift.
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Used all available assists on the equipment and in the ambulance.
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Lift/transfer was gradual, smooth motion with no jerking?
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Turned body with feet and avoided unnecessary twisting when positioning the patient on the equipment.
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Lift/transfer plan was implemented as planned?
AT HOSPITAL/TRIAGE
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Stretcher correct height
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All restraints secure
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Patient advised not to move
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Patient was not left unattended
TRANSFERRING FROM STRETCHER TO HOSPITAL BED
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Communicated sequence of transfer with patient, partner and other agency personnel
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Stretcher correct height
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Slider board used
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Correct lifting techniques
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Sufficient personnel
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Communication with all personnel involved
DEBRIEF WITH CREW
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Input from crew
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Feedback to crew
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Evaluation form to crew
ADDITIONAL COMMENTS OF INSPECTOR(S):
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Any other comments, especially related to any increased risk of MSI, when conducting the lift or transfer?
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OBSERVED BY DOSH MEMBER (Print & sign first/last name)
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Select date
