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A Safety Risk Assessment for Healthcare Facility Environments

Safety Risk Assessment (SRA) for healthcare facility environments This toolkit has been created through a consensus process of experts in the safety risk areas. The Center for Health Design extends its gratitude to all the participants and volunteers that supported content development and testing. The Center also thanks the three pilot sites who made their project teams available for testing: Barnes-Jewish Hospital, University of California Irvine Medical Center, and Memorial Sloane Kettering Cancer Center.

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DISCLAIMERS: This tool is not intended to be a guarantee of a safe environment; the environment is one part of a safety solution that includes operational policies and procedures and behavior of people. It is intended for use with collaborative input of project and facility-based expertise. This tool is also not a comprehensive list of guideline requirements but provides a high-level overview of certain considerations and their relationship to safety. This toolkit has been created with support from the Agency for Healthcare Research and Quality (AHRQ) Grant R13HS021824 and the Facility Guidelines Institute (FGI). The content is solely the responsibility of the authors and does not necessarily represent the official views of the Agency for Healthcare Research and Quality. Copyright 2012-2015 The Center for Health Design. All Rights Reserved. The Excel version of this tool may only be used with an active Affiliate Plus membership with The Center for Health Design. This tool may not be used by, transferred to or copied to any other party. The legend may not be removed from the tool or accompanying materials. The user may not make derivative work, remixes, transform, or build upon or distribute the tool or accompanying materials. The authorized PDF version, accompanied by the Creative Commons License page, is licensed under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-nc-nd/4.0/. The Center for Health Design: 1850 Gateway Boulevard, Suite 1083; Concord, California 94520 USA; Phone: 925.521.9404; Fax: 925.521.9405

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Volunteers

A Safety Risk Assessment for Healthcare Facility Environments

Home The Core Team 1 Anjali Joseph, PhD, EDAC, former Director of Grants and Research Advisory Services, The Center for Health Design; Endowed Chair in Architecture+Health Design and Research, Assoc. Prof. of Architecture, Clemson University 2 Ellen Taylor, AIA, MBA, EDAC, Director of Research, The Center for Health Design 3 Xiaobo Quan, PhD, EDAC, Senior Research Associate, The Center for Health Design 4 Upali Nanda, PhD, Assoc. AIA, EDAC, former Research Consultant, The Center for Health Design; Vice President and Director of Research, HKS Inc. / Executive Director, CADRE 5 Catherine Ancheta, Project Manager, The Center for Health Design 6 Debra Levin, EDAC, President and CEO, The Center for Health Design

The many volunteers that made this toolkit possible include (listed alphabetically): Advisory Council 7 Doug Bonacum MBA, CSP, CPPS, VP, Quality, Safety, and Resource Management, Kaiser Permanente 8 Carol Corr, AIA, EDAC, LEED, Green Associate Design Manager, Facilities Planning and Design, National Facilities Services Kaiser Permanente 9 Terry Fairbanks, MD, MS, Director of the National Center for Human Factors Engineering in Healthcare, and Acting Director of the Simulation & Training Environment Laboratory (SiTEL), MedStar Institute for Innovation (MI2) 10 Ella Franklin, RN, CRC, EDAC, Director, Infection Prevention Research and Innovation, MedStar Institute for Innovation (MI2) 11 Tejas Gandhi, Chief Administrative Officer, The Medical Center of Central Georgia 12 John Kouletsis, AIA, EDAC, Vice President, Facilities Planning & Design, National Facilities Services, Kaiser Permanente 13 Jim Lussier, Founder & President, The Lussier Center 14 Eileen Malone, RN, MSN, MS, EDAC, Senior Partner, Mercury Healthcare Consulting, LLC (also a workgroup leader) 15 Chris McCarthy, MPH, MBA, Director, Innovation Learning Network 16 John Reiling, PhD, MBA, MHA, President & CEO, Safe by Design / Adjunct Professor, University of Minnesota, University of St. Thomas

Workgroup Leaders 17 Maggie Calkins PhD, President & Board Chair, IDEAS Institute / Elliot Professor in Health Care Design, Kent State University, College of Architecture and Environmental Design 18 Linda Dickey, RN, MPH, CIC, Director, Epidemiology & Infection Prevention, UC Irvine Health 19 Mary Matz, MSPH, CPE, CSPHP, Consultant, Patient Care Ergonomics, Patient Care Ergonomic Solutions, LLC 20 Kelsey McCoskey, MS OTR/L, CPE, CSPHP, Ergonomist, Occupational Therapist, US Army Public Health Command 21 Mardelle Shepley, FAIA, EDAC, LEED AP, Professor - Design + Environmental Analysis, Cornell University College of Human Ecology 22 Tony York, CPP, CHPA, Chief Operating Officer, HSS

Subject Matter Experts and Pilot Test Participants 23 The Barnes-Jewish Hospital team in St. Louis, MO 24 The University of California Irvine Medical Center team in Irvine, CA 25 The Memorial Sloan Kettering Cancer Center team in New York, NY

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Volunteers

A Safety Risk Assessment for Healthcare Facility Environments

Home 26 Carmen Adams DNSc, RNC, Strategic Leader, Quality, Kaiser Permanente 27 David Allison FAIA, ACHA, Professor/Director, Graduate Studies in Architecture + Health Clemson University 28 Helen Archer-Duste RN, MS, Executive Director, Workplace Safety and Care Experience Kaiser Permanente 29 Angelene Baldi, AIA, EDAC, LEED GA, Planning Manager for Facilities Planning and Design, Kaiser Permanente 30 Sue Barnes RN, CIC, Infection Prevention and Control Quality and Safety Department, Kaiser Permanente 31 Donna Bohannon R. Ph., CPPS Scientific Liason, U.S. Pharmacopeial Convention 32 Doug Bonacum MBA, CSP, CPPS, VP, Quality, Safety, and Resource Management, Kaiser Permanente 33 Sheila Bosch PhD, LEED AP, EDAC Director of Research, Gresham, Smith & Partners 34 Barbara Braun PhD, Associate Director, Department of Health Services Research, Division of Healthcare Quality Evaluation, The Joint Commission 35 Rosalyn Cama FASID, EDAC President CAMA, Inc. 36 Pascale Carayon, PhD, Procter & Gamble Bascom Professor in Total Quality Department of Industrial and Systems, Engineering, Director of the Center for Quality and Productivity Improvement University of Wisconsin-Madison 37 Satyan Chari, BOT, Grad Cert Occ Thy, M Sc Occ Thy, Program Coordinator - Falls Risk/OHMR, Research Fellow, Royal Brisbane and Women's Hospital,Queensland Health 38 Young-Seon Choi, PhD, March, Assistant Professor Department of Architecture, Kyungil University, South Korea 39 Eileen Costantinou, RN, MSN, BC, Practice Specialist, Senior Coordinator, Barnes-Jewish Hospital 40 Tom Davis, Director of Facilities Management & Security, University of Colorado Hospital 41 Marie DePerio, Medical Officer, CDC/NIOSH 42 Lena Deter, RN, MPH, CSPHP, Clinical Specialist in Patient Safety, DELHEC LLC 43 Anthony Donaldson, CSPHP, National Environmental, Health and Safety Senior Staff Manager, Kaiser Permanente 44 Lori Dowling, President, ECORE Commercial Flooring 45 Jan Ehrenwerth, MD, Professor of Anesthesiology; Director, Vascular Yale University School of Medicine 46 Doug Erickson, FASHE, CHFM, HFDP, CHC, CEO, Facilities Guidelines Institute 47 Bill Felkey, BA, MS, Professor Emeritus, Auburn University 48 John Fishbeck, Associate Project Director, The Joint Commission 49 June Fisher, MD, Director, TDICT Project, Trauma Foundation/NIOSH 50 Guy Fragala, PhD, PE Senior Advisor for Ergonomics, Patient Safety Center of Inquiry 51 Susan Gallagher, RN, Bariatric Expert, Independent Consultant 52 John Grout, PhD, Dean, Campbell School of Business, Berry College 53 Ed Hall, MS, CSP, Chief Operating Officer, The Stanford University Medical Network Risk Authority 54 Kendall Hall, MD, MS, Scientific Director, MedStar SiTEL, MedStar Health 55 D. Kirk Hamilton, FAIA, FACHA, EDAC, Professor of Architecture, Texas A&M University 56 Eve Hanna, MD, MPH, Occupational Health Physician, James A Haley Veteran’s Hospital 57 Daniel Hartley, Ed.D., Epidemiologist, NIOSH Workplace Violence Prevention Coordinator, NIOSH

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A Safety Risk Assessment for Healthcare Facility Environments

Home 58 William Heath, RPh, MBA, FAPhA, Col (retired), Consultant to USP, APhA, ASHP, Heath Healthcare Consulting, Inc., U.S. ARMY 59 Dennis Hemphill, CPP, System VP - Safety, Security, Emergency Management, Dignity Health 60 Prof. Sue Hignett, PhD, Professor of Healthcare Ergonomics & Patient Safety, Postgraduate Programme Director for Ergonomics & Human Factors, Chair of Education & Training Panel, Chartered Institute of Ergonomics & Human Factors, Loughborough University 61 Robert Hody Asst. Director, Lean Sigma Deployment Johns Hopkins Medicine 62 Vicky Hogue, RN, MSN, CCRN, EDAC, VP Patient Services/CNO, Wellstar Paulding Hospital 63 Daniel Horan, INCE, LEED AP BD+C, Senior Consultant, Cavanaugh Tocci Associates, Inc. 64 Kimberly Hudson, RN, MSN, Safe Patient Handling Coordinator, Marion VAMC 65 Robert Hunn, MBA, CHFM, CHSP, LEED AP BD&C, EDAC, Director of EH&S, University of Kansas Hospital 66 Jim Hunt, AIA, NCARB, President, Behavioral Health Facility Consulting 67 Tamara James, CPE, Ergonomics Director, Duke University and Health System 68 Mandy Kachur, PE, INCE Board Certified Principal Consultant, Soundscape Engineering LLC 69 Hanneke Knibbe MSc, RPT Owner, LOCOmotion 70 Joe Kucharz, Director, Healthcare Real Estate, Navigant 71 Don MacAlister, CHPA, Vice President, Paladin Security 72 Jennifer MacDaniel, Project Principal, Innovations Group, Kaiser Permanente 73 Kathy Maher, RN, MSN, Manager, Employee Health Services, UW Medicine Harborview Medical Center 74 Jain Malkin, CID, AAHID, EDAC, President, JAIN MALKIN INC. 75 Larry Mallak, PhD, Professor, Western Michigan University 76 Kirsten Martin, RN, MBA, CHE, Consultant, Planning & Development, St. Michael's Hospital 77 Marie Martin, PhD, Industrial Hygienist (SPHM Facility Coordinator), VA North Texas Health Care System 78 Susan McCrone, PhD, RN, Professor and Coordinator. CDC/NIOSH 79 Kate McPhaul, PhD, MPH, RN, Deputy Chief Consultant, Occupational Health (10P3D) Office of Public Health, Veterans Health Administration 80 David Meek, RN, MA, BSN, BEd, CEN, CLNC, CEM Founder, The National Institute for Elopement Prevention & Resolution 81 Bart Miller, CHFM, CHC, CHSP, CHEP, SASHE, Director of Construction/Plant Operations/Bio-Medical Services, St. Mary Medical Center 82 Peter Mills, PhD, MS, Director, VA National Center for Patient Safety Field Office, Veterans Affairs Medical Center / Adjunct Associate Professor of Psychiatry, The Geisel School of Medicine at 83 Richard Moeller, PE, FASHE, HFDP, LEED AP, CHC, Principal, Mazzetti 84 Patricia Morrill, PMP, EDAC, President, PM Healthcare Consulting, LLC 85 Ellen Murphy, MS, JD, FAAN, Professor Emerita, University of Wisconsin 86 Mahiyar Nasarwanji, PhD, Post-doctoral Research Fellow, Armstrong Institute for Patient Safety and Quality 87 Samira Pasha, PhD, EDAC, LEED AP BD+C, Senior Designer, RTKL 88 Erin Peavey, LEED AP BC+D, EDAC, Researcher + Medical Planner, HOK 89 Catherine Porzio, AIA, Associate, HKS Inc.

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Volunteers

Home 90 Dana Ragouzeos, Design Research Lead, Innovation Consultancy 91 Marilyn Ridenour, BSN, MBA, MPH, Nurse Epidemiologist, CDC/NIOSH 92 Sheila Ruder, AIA, ACHA, EDAC, LEED AP, Lean Six Sigma CE, Vice President HKS Inc. 93 Abelardo Ruiz, Innovations Group, Kaiser Permanente - Facilities Planning & Design 94 Richard Schleckser, MS, ARM, NEBOSH, CMIOSH, CSPHP, Sr. Service Director, Liberty Mutual Insurance 95 Jonas Shultz, MSc, Human Factors Lead, Health Quality Council of Alberta 96 David Sine, CSP, ARM, Chief Risk Officer, Department of Veterans Affairs 97 Brian Smith, Six Sigma Black Belt, Healthcare Consultant 98 Ron Smith, AIA, ACHA, ACHE, EDAC, President & CEO, Design At The Intersection, LLC 99 Tom Smith, CHPA, CPP, President, Healthcare Security Consultants, Inc. 100 Elizabeth Stanberry, PharmD, Chief of Pharmacy, VA New Jersey Health Care System 101 Erica Stewart, CIH, HEM, National Environmental, Health and Safety, Principal Consultant, Kaiser Permanente 102 Andrew Streifel, MPH, REHS, Hospital Environmental Specialist, University of Minnesota 103 Dana Swenson, Senior Vice President, Umass Memorial Medical Center 104 Terry Thurston, RN, BSN, MBA, Director, Healthcare Operations Planning, BSA LifeStructures 105 Rein Tideiksaar, PhD, PA-C, President, Fallprevent, LLC 106 Kevin Tuohey, Executive Director - Research Compliance, Boston University & Boston Medical Center 107 David Uhaze, RA, Chief - Bureau of Construction Project Review, State of NJ Department of Community Affairs 108 Susan Wagner-Debusman, RN, Employee Health Program Manager, Kaiser Permanente 109 Thomas Wallen, AIA, ACHA, Vice President, Healthcare Performance Partners, Inc. 110 Frank Weinberg, Corporate Assistant Vice President of Facilities, MedStar Health, Inc. 111 Salley Whitman, MHA, Director of Operations, NXT Health 112 Lynn Willis, MHA, MHA, Regulatory Compliance Programs Manager, UC Irvine Medical Center 113 Laurie Wolf, MS, CPE, Performance Improvement Engineer, Barnes-Jewish Hospital

and Additional Staff from The Center for Health Design Alison Berger, Project Manager Anna Gasparini, Office Manager Carolyn Glaser, MA, EDAC, Director of Operations Donna Deckard, BSN, MPA, EDAC, Director of Strategic Projects Linda P. Franklin, Senior Marketing Communications Manager Shannon Roecklein, Project Manager

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A Safety Risk Assessment for Healthcare Facility Environments

Home It may seem overly simple to indicate a list of safety features that can improve safety, but patient safety begins with an awareness of safety features maintained within the facility. Poorly designed and operated healthcare environments contribute to adverse events and subsequent patient harm, such as healthcare-associated infections (HAIs), medication errors and patient falls.

The goal of this tool is to provide guidance to consider the underlying (latent) conditions that can lead to harm. This tool supports the requirement for a safety risk assessment (SRA) found in the 2014 FGI Guidelines for Design and Construction of Hospitals and Outpatient Facilities.

A large and growing body of evidence indicates that the physical environment impacts patient and staff safety, as well as stress and satisfaction; staff effectiveness; and organizational resource outcomes in hospitals and other healthcare settings. Facility replacement and renovation projects provide an opportunity to identify and mitigate or eliminate built environment latent conditions that may lead to active failures impacting patient safety.

There are six components of consideration: infection control, patient handling, medication safety, falls, behavioral health, and security. You may want to get started by looking at some high-level concepts and considerations in the Safe Design Roadmap.

Skip the Safe Design Roadmap Get Started with Project Information

Take Me to the Safe Design Roadmap

I'm ready to go directly to the risk data and design considerations

Infection Control

Patient Handling

Falls

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Medication Safety

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Behavioral Health

Security

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Safe Design Roadmap Intro

A Safety Risk Assessment for Healthcare Facility Environments

Home

Project Data

The Risk Component Links

Glossary/Definitions

Safe Design Roadmap Introduction

Next: Take Me to the Safe Design Roadmap Questions

A well-designed healthcare facility literally shapes all healthcare delivery, directly and indirectly underpinning patient and staff safety. Evidence shows that poorly designed and operated healthcare environments contribute to adverse events and subsequent patient harm, such as HAIs, medication errors and patient falls. Facility replacement and renovation projects provide an excellent opportunity to proactively identify and eliminate building-related features that may lead to harm for patients and staff.

The Safe Design Roadmap provides a tool that enables CEOs and leadership team to identify and implement key strategies that ensure their facility project is strongly focused on patient and staff safety. Completing this self-evaluation tool, modeled on the American Hospital Association’s Second Curve Road Map for Health Care , helps leaders ensure that an organization’s strategy to use evidence-based practices to improve quality and patient safety are integrated with the facility design process.

Designing a healthcare facility is a complex process that requires a careful balance of many priorities. From the first moment a facility project is considered, it is critical to make safety a priority, so that safety issues are immediately identified and become a central focus of all subsequent planning, design and construction activities. It is usually cost-prohibitive to ameliorate design-related safety concerns once a building is under construction, built or occupied. There are significant financial advantages of designing for safety.

The companion Safety Risk Assessment (SRA) tool is used by the multidisciplinary facility project team, providing them with more evidence-based information about how to use built environment design to help mitigate the following safety issues: healthcare-associated infections; patient falls, medication safety; patient handling and movement; patient immobility; security and elopement and behavioral health and psychiatric injury. In addition to patient safety, both tools also focus on staff safety as an important project consideration.

Figure 1: The SRA Cost-Influence Curve (Based upon Taylor, Hignett, and Joseph, 2014)

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Safe Design Roadmap Intro

A Safety Risk Assessment for Healthcare Facility Environments

Safe Design Roadmap Introduction

Next: Take Me to the Safe Design Roadmap Questions

The Safe Design Roadmap self-assessment tool is organized around the various phases of the facility lifecycle: 1) Strategic & Operational Planning. This phase reflects the organization’s high-priority strategies, supported by a concept of operation achieved through the creation of operational planning and performance improvement projects to realize patient and staff safety goals. 2) Programming & Design. During the program and design phase, the concept of operations is translated into the amount of space required and then the design of the facility itself. Designs are submitted in an iterative fashion, beginning with more general designs, such as block adjacency drawings (e.g., radiology is located next to the emergency department), to the specific, such as hardware specification and furnishing material selection.

3) Construction & Commissioning. Construction, which sometimes begins before the design is finished, includes the clearing of the site and all activities involved in actually building the facility, including the placement of some built-in equipment and furniture. During the commissioning phase, the building is outfitted with all additional equipment, furniture, medical and administrative supplies and other essential healthcare materials. 4) Sustainment. The phase begins with occupancy of the building and includes all of the routine maintenance and repair activities necessary to keep the building in good working order over the life of the building.

Definitions of Project Phases

Next: Take Me to the Safe Design Roadmap Questions

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Safe Design Roadmap Project Data

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The Risk Component Links

This assessment tool has four sections that correspond to a facility project lifecycle, in order to support a healthcare organization’s strategy to use evidence-based practices to improve patient and staff safety.

Phase

Rating Scale

Successfully launching the facility project (strategic planning, facility master planning, process and operational planning)

1: Not developed or just starting

Glossary/Definitions

For each section, evaluation statements are provided to assess your hospital or clinic’s position as you enter each project phase: strategic and process planning; programming and design; construction and commissioning; and sustainment. To complete the assessment, please evaluate the organization’s status for each evaluation statement:

Key Safety Questions 2: in process

A Safety Risk Assessment for Healthcare Facility Environments

Item Notes 3: fully developed, working well.

We focus on safety as both a strategic and operational goal, as reflected in our mission, vision and values statements. We examined root cause analysis and other performance improvement projects to identify safety improvement opportunities. We identified specific safety goals for the project (e.g., reduce patient healthcareassociated infections, falls, medication errors, staff musculoskeletal injuries, injuries associated with patient and staff violence). We evaluated the impacts on reimbursement (e.g., CMS’ Inpatient Prospective Payment System and Hospital Value-Based Payment program) consequent to present safety outcome results. We identified fiscal improvement targets for safety outcomes that the project will help to achieve. We began an ROI for equipment purchases (e.g., ceiling-mounted lifts, ultraviolet gamma irradiation) needed to support identified safety goals. We considered the role that safety has on the brand recognition of our organization. We included safety as a key priority in the guiding principles for the project. We hired an A-E and project team with proven expertise in designing for safety. We oriented the design team to our safety culture and priorities.

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#DIV/0! 1 2 3

4 5 6 7 8 9 10

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Safe Design Score (average rating)

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Safe Design Roadmap Key Safety Questions

Item Notes

Strategic planning, facility master planning, process and operational planning (continued)

Rating Scale

We identified safety as a high priority during the visioning session used to launch the project.

11

The project vision and goals were communicated to key stakeholder groups (Board, Medical Staff, Staff, Patients, Community).

12

We ensured that the project team provided the key stakeholders with an overview of EBD features that research reveals contribute to improved safety

13

Aligning the design to support the strategic vision and goals for the project (Programming and design)

Phase

A Safety Risk Assessment for Healthcare Facility Environments

We approved a functional program that accommodates safety features to support our goals. With the design team, we developed statements that highlight how the proposed safety features will improve our safety metrics. We identified the baseline, pre-occupancy safety metrics that will be used for comparison purposes during post-occupancy measurements. We reviewed the evidence and completed the Safety Risk Assessment to identify specific safe design features we will include in the project. As appropriate, we identified environmental safety features missing in our present environment for comparison purposes and to facilitate an understanding of care processes that may require reengineering. We used different tools such as virtual tools and mock-up rooms to understand how design features may support our safety culture and processes.

We aligned processes of care using safety as a focus.

14

As appropriate, we assigned multidisciplinary staff members to support the facility project.

We ensure that the design supports the desired safety concepts of operation from all perspectives: patients, family and visitors, the community, staff, material movement, equipment and technology use. During the programming and design phases, we ensure that critical safety design features are not lost (e.g., during design development – design works from the general to the specific, value reengineering). We updated the safety equipment ROI.

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15 16 17 18 19 20

21

22

23 24

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Safe Design Roadmap

Maximizing the facility investment (Sustainment)

Maintaining the project’s vision and goals and reengineering culture and processes (Construction and commissioning)

Phase

Rating Scale

Key Safety Questions

A Safety Risk Assessment for Healthcare Facility Environments Item Notes

During the construction and commissioning phases, we ensure that critical safety design features are not lost.

25

We finalized care processes reengineering based on the design of the new facility.

26

We modified our existing comprehensive safety program to reflect the safety design features and reengineered processes of care.

27

We established training programs, which integrate the new safety design features, equipment and reengineered care processes.

28

To the degree possible, we implemented the new care processes in our present environment.

29

As needed, we updated the safety equipment’s ROI.

30

As appropriate, we informed key stakeholders about the emerging safetyfocused design features. We collected the final pre-occupancy measures for targeted safety outcomes. We regularly report on all relevant data points for patient and staff safety, including the same pre-occupancy safety measures now monitored longitudinally during the post-occupancy. We completed the ROI.

31 32

33 34

We informed key stakeholders (e.g., board, staff, patients, community) when the ROI was met.

35

We captured the stories associated with the project and shared them with our stakeholders and interested national audiences.

36

We evaluated the results of our safety program investments through the use of longitudinal post-occupancy measures and shared those results at conferences and meetings, in peer-reviewed journals and in trade industry magazine, website and blog articles.

37

We observed positive safety trends.

38

We implemented a facility maintenance and repair plan that ensures the integrity of safety design features over the life of the building.

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Project Data Home

Safe Design Roadmap

A Safety Risk Assessment for Healthcare Facility Environments Glossary/Definitions

The Risk Component Links

Project Background Information and Data

Project Name

Construction

Initiated by (name):

Organization

New Construction

Major Renovation

Renovation changing function of space

Minor/minimal renovation Other

Project

Consider the location where there is a risk of the hazard components. All projects need to consider:

Infection Control

Security

Does your project include any of the Areas where patient handling, transport, transfer and following? movement occur? Complete Patient Handling Assessment Areas where behavioral health patient treatment occurs? Complete Behavioral Health Injury Assessment

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Areas where medication preparation, processing and distribution occur? Complete Medication Safety Assessment Areas where a patient or family member has access? Complete Falls Assessment

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RiskComponentLinks

Risk Components

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Infection Control

Patient Handling

A Safety Risk Assessment for Healthcare Facility Environments

Infection Control Risk and Historic Data

Falls

Infection Control Design Considerations

Falls Design Considerations

Infection Control Risk Assessment (ICRA) Matrix of Precautions (tab in file)

CDC report - Slips, Trips, and Falls: Healthcare Workers (outside link)

Patient Handling Risk and Historic Data

Behavioral Health

Patient Handling and Assessment White Paper (outside link)

Medications Safety Risk and Historic Data

Behavioral Health and Psychiatric Injury Risk and Historic Data Behavioral Health and Psychiatric Injury

Patient Handling Design Considerations

Medication Safety

Falls Risk and Historic Data

Behavioral Health Facility Guidelines (links to FGI Beyond Fundamentals)

Security

Security Risk and Historic Data

Medication Safety Design Considerations

Security Design Considerations

USP General Chapter Physical Environments (outside link)

IAHSS Security Guidelines information (outside link)

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Infection Control Risk Data Design Considerations: Infection Control

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Project Data

Infection control includes airborne, surface and water transmission issues. The CDC and Patient Safety & Quality Healthcare sites including National Nosocomial Infections Surveillance (NNIS) provide information about statistics and the implications of infections. Risks for specific HAIs are associated with multiple factors including building construction type, healthcare service types and patient populations.

A Safety Risk Assessment for Healthcare Facility Environments

Safe Design Roadmap

The Risk Component Links

Glossary/Definitions

For at-risk populations, identify potential harms and areas within the proposed project associated with those potential harms. Consider the patient risk groups (spaces) to be affected and the potential outcomes, including during construction. Is the likelihood rare or almost certain? Is the consequence negligible or minor injury or a sentinel event?

The degree of potential harm related to HAIs may vary across at-risk populations and other factors. An organization may invest more resources in areas associated with a relatively higher degree of potential harm. A panel of experts created a generic level of risk, but this should be considered with respect to your own organization and patient demographic. You might consider a typical “heat map” of risk throughout your decision process. A sample is shown here.

Consequence

Likelihood Rare

Possible

Unlikely

Likely

Sentinel event Partial disability Medical treatment First aid No injury or disability

See the ICRA Matrix of Precautions for Construction & Renovation for assessing risk consequence and likelihood.

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Almost Certain

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Infection Control Risk Data

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Design Considerations: Infection Control

Project Data

Evaluate historical data to ascertain all conditions (e.g., construction type, service type, patient populations) that contribute to HAIs in both inpatient and outpatient areas in your facility. Infection Type

Location/Unit Type

Rate

Copyright 2012-2015 The Center for Health Design. All Rights Reserved.

A Safety Risk Assessment for Healthcare Facility Environments

Safe Design Roadmap

The Risk Component Links

Glossary/Definitions

Past performance does not guarantee future results, but this may help identify the likelihood of events specific to the organization. Are there patterns of vulnerability?

Subject Matter Expert Consulted (Name)

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Title/Role

Data Source

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ICRA Matrix

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Design Considerations: Infection Control

Project Data

A Safety Risk Assessment for Healthcare Facility Environments

Safe Design Roadmap

The Risk Component Links

Glossary/Definitions

Infection Control Risk Assessment (ICRA) Matrix of Precautions

(https://www.premierinc.com/quality-safety/tools-services/safety/topics/construction/icra.jsp) Step 1 Using the following table, identify the Type of Construction Project Activity (Type A-D) Type A

Inspection and non-invasive activities Includes, but is not limited to: removal of ceiling tiles for visual inspection only, e.g., limited to 1 tile per 50 square feet; painting (but not sanding); wallcovering, electrical trim work, minor plumbing and activities which do not generate dust or require cutting of walls or access to ceilings other than for visual inspection.

Type B

Small scale, short duration activities which create minimal dust Includes, but is not limited to: installation of telephone and computer cabling; access to chase spaces; cutting of walls or ceiling where dust migration can be controlled.

Type C

Work that generates a moderate/high level of dust or requires demolition/removal of any fixed building components/assemblies Includes, but is not limited to: sanding of walls for painting or wall covering; removal of floorcovering, ceiling tiles and casework; new wall construction; minor ductwork or electrical work above ceilings; major cabling activities; any activity which cannot be completed within a single workshift.

Type D

Major demolition and construction projects Includes, but is not limited to: activities which require consecutive workshifts; require heavy demolition or removal of a complete cabling system; new construction.

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ICRA Matrix

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Design Considerations: Infection Control

Project Data

A Safety Risk Assessment for Healthcare Facility Environments

Safe Design Roadmap

The Risk Component Links

Step 2

Low Risk Office areas

Medium Risk Cardiology Echocardiography Endoscopy Nuclear Medicine Physical Therapy Radiology/MRI Respiratory Therapy

High Risk CCU Emergency Room Labor & Delivery Laboratories (specimen) Medical Units Newborn Nursery Outpatient Surgery Pediatrics Pharmacy Post-anesthesia Care Unit Surgical Units

Highest Risk Any area caring for immunocompromised patients Burn Unit Cardiac Cath Lab Central Sterile Supply Intensive Care Units Negative pressure isolation rooms Oncology Operating rooms including C-section rooms

Step 3 Match the Patient Risk Group (Low, Medium, High, Highest) with the planned … Construction Project Type (A, B, C, D) on the following matrix, to find the … Class of Precautions (I, II, III or IV) or level of infection control activities required. Patient Risk Group LOW Risk Group MEDIUM Risk Group HIGH Risk Group HIGHEST Risk Group

Type A I I I II

Type B II II II III/IV

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Type C II III III/IV III/IV

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Type D III/IV IV IV IV

Glossary/Definitions

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ICRA Matrix

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Design Considerations: Infection Control

Project Data

A Safety Risk Assessment for Healthcare Facility Environments

Safe Design Roadmap

The Risk Component Links

Glossary/Definitions

Step 4 Identify the areas surrounding the project area, assessing potential impact: Unit Below

Unit Above

Lateral

Lateral

Behind

Front

Risk Group

Risk Group

Risk Group

Risk Group

Risk Group

Risk Group

Step 5 Identify specific site of activity, e.g., patient rooms, medication room, etc. Step 6 Identify issues related to: ventilation, plumbing, electrical in terms of the occurrence of probable outages. Step 7 Identify containment measures, using prior assessment. What types of barriers? (e.g., solid wall barriers); Will HEPA filtration be required? Step 8 Consider potential risk of water damage. Is there a risk due to compromising structural integrity? (e.g., wall, ceiling, roof)?

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ICRA Matrix

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Design Considerations: Infection Control

Project Data

A Safety Risk Assessment for Healthcare Facility Environments

Safe Design Roadmap

Step 9 Work hours: Can or will the work be done during nonpatient care hours?

Step 10 Do plans allow for adequate number of isolation/negative airflow rooms?

Step 11 Do the plans allow for the required number & type of handwashing sinks?

Step 12 Does the infection prevention & control staff agree with the minimum number of sinks for this project? (Verify against FGI Design and Construction Guidelines for types and area.) Step 13 Does the infection prevention & control staff agree with the plans relative to clean and soiled utility rooms?

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The Risk Component Links

Glossary/Definitions

20

ICRA Matrix

Home

Design Considerations: Infection Control

Project Data

A Safety Risk Assessment for Healthcare Facility Environments

Safe Design Roadmap

The Risk Component Links

Step 14 Plan to discuss the following containment issues with the project team, e.g., traffic flow, housekeeping, debris removal (how and when).

Appendix: Identify and communicate the responsibility for project monitoring that includes infection prevention & control concerns and risks. The Infection Control Risk Assessment (ICRA) may be modified throughout the project. Revisions must be communicated to the Project Manager.

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Glossary/Definitions

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100-Infection Control Design

103 Include adequate number of negative isolation rooms for airborne infectious patients in patient care areas based on projected number of such patients during normal and contingent surge operations.

104 Include adequate number of positive-pressure isolation rooms for high-risk, immuno-compromised patients in the patient care areas based on projected number of such patients during normal and contingent surge operations.

Copyright 2012-2015 The Center for Health Design. All Rights Reserved.

Safe Design Roadmap

Cost Magnitude

Your Priority

Generic Risk Estimate Med-High Med-High Highest

101 Include physical separation/ isolation methods (e.g., separate soiled workroom, supply chain flow separation) in unit layout to prevent contamination of clean supplies and equipment. 102 Include physical separation /isolation methods in rooms to prevent cross-transmission between patients (e.g., single room, appropriate physical distance/separation between roommates if multi-bed rooms are used).

Highest

Sort #

What is being discussed? (Design Consideration)

Your Risk Estimate

Project Data

Risk Data: Infection Control

A Safety Risk Assessment for Healthcare Facility Environments

Why should this be considered? (Rationale) (This cell hyperlinks to references) The contamination of linen and other supplies increase the risk of infections. Physical separation (e.g., a separate soiled workroom) is an important method of preventing the transfer of pathogens from soiled to clean linen, equipment and other supplies. Direct and indirect contact constitute a major route of pathogen transmission between patients (Chang & Nelson, 2000). Reducing the chances of direct/indirect contact between patients through physically separating and isolating patients, especially the provision of single-bed patient rooms, has been associated with significantly lower risks of HAI's and better health outcomes (MacKenzie et al., 2007; McManus, Mason, McManus, & Pruitt, 1992). Contaminated air flowing from rooms where air-borne infectious patients stayed was reported to increase the risks of infections among patients and staff in nearby spaces (Gustafson et al., 1982; Hutton, Stead, Cauthen, Bloch, & Ewing, 1990). Research strongly suggests that air-borne infectious patients should be isolated in negative-pressured rooms to minimize the risk of cross-contamination by preventing contaminated air flowing from isolation rooms to nearby spaces (Sehulster & Chinn, 2003). Immunocompromised patients are particularly vulnerable to infections. Research strongly suggests that immunocompromised patients should be isolated in positive-pressured rooms to minimize the risk of contracting air-borne pathogens by preventing potentially contaminated air from flowing from nearby spaces into the isolation rooms (Sehulster & Chinn, 2003).

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Location Key: GEN = General Consideration; OL = Overall Layout; IP = Inpatient; D&T = Diagnostic & Treatment; Rx = Pharmacy; ED = Emergency Department; HIM = Med. Records/Health Information Mgmt; OR = Operating; SEC = Seclusion

Sort #

Glossary/Definitions

The Risk Component Links

What is being discussed? (Design Consideration)

How is this done? Explanations/Clarifications (How Accomplished, Reasons Against)

101 Include physical separation/ isolation methods (e.g., separate soiled workroom, supply chain flow separation) in unit layout to prevent contamination of clean supplies and equipment. 102 Include physical separation /isolation methods in rooms to prevent cross-transmission between patients (e.g., single room, appropriate physical distance/separation between roommates if multi-bed rooms are used). 103 Include adequate number of negative isolation rooms for airborne infectious patients in patient care areas based on projected number of such patients during normal and contingent surge operations.

104 Include adequate number of positive-pressure isolation rooms for high-risk, immuno-compromised patients in the patient care areas based on projected number of such patients during normal and contingent surge operations.

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B = Body (required); A = Appendix (suggested); N/I or blank = not included

Location

Risk Data: Infection Control

A Safety Risk Assessment for Healthcare Facility Environments

FGI

22

100-Infection Control Design

Building category

GEN

Unit Layout

B

GEN

Room Layout

B

GEN

Unit Layout

B

GEN

Unit Layout

B

23

100-Infection Control Design

105 Provide a sufficient number of hand hygiene devices to support convenient use by staff, patients and families. (This consideration is also relevant under the following category: room layout)

108 Position sink location so that splashes from the sinks cannot reach the patient zone or clean supplies.

Med-High

107 Design room layout to allow easy visual and physical access to hand hygiene devices (such as sinks, alcohol hand rub dispensers, etc.).

Highest

Highest

106 Designate a single-patient use bathroom for each patient for the duration of their stay on the unit.

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Safe Design Roadmap

Cost Magnitude

Your Priority

Generic Risk Estimate Highest

Sort #

What is being discussed? (Design Consideration)

Your Risk Estimate

Project Data

Risk Data: Infection Control

A Safety Risk Assessment for Healthcare Facility Environments

Why should this be considered? (Rationale) (This cell hyperlinks to references) Hand hygiene is considered the single most important method of infection prevention because pathogens are often transferred via the unwashed hands of staff, patients and families. The number of hand hygiene devices is an important factor significantly impacting hand hygiene performance. More sinks, gel dispensers, and other hand hygiene devices likely make it easier for staff, patients and families to gain access to the devices and clean their hands when needed (Kaplan & McGuckin, 1986). Shared bathrooms may serve as reservoirs of infectious pathogens discharged from one patient and contribute to the transmission of the pathogens to other patients who use the same bathroom during the same time period. Even in bathrooms less frequently used by patients, pathogens could be brought in through staffs hands or used equipment and supplies. Single-patient bathroom may help reduce cross-contamination and improve environmental cleanliness. Hand hygiene is considered to be the single most important method of infection prevention because pathogens are often transferred via the unwashed hands of staff. Well located hand hygiene devices may make it easy for staff and other individuals to see and use the devices to clean their hands. Water splashes from sinks to nearby patient care areas have been found to increase risk of contamination and infection transmission of water-borne pathogens. Research has found that the location and orientation of hand hygiene devices are important factors that impact the possibility of water being splashed from sinks reaching nearby patient care area (Hota et al., 2009).

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Sort #

Glossary/Definitions

The Risk Component Links

What is being discussed? (Design Consideration)

How is this done? Explanations/Clarifications (How Accomplished, Reasons Against)

105 Provide a sufficient number of hand hygiene devices to support convenient use by staff, patients and families. (This consideration is also relevant under the following category: room layout)

B = Body (required); A = Appendix (suggested); N/I or blank = not included

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Risk Data: Infection Control

A Safety Risk Assessment for Healthcare Facility Environments

FGI

24

100-Infection Control Design

Building category

GEN

Unit Layout

B

GEN

Room Layout

B

GEN

Room Layout

B

GEN

Room Layout

106 Designate a single-patient use bathroom for each patient for the duration of their stay on the unit.

107 Design room layout to allow easy visual and physical access to hand hygiene devices (such as sinks, alcohol hand rub dispensers, etc.). 108 Position sink location so that splashes from the sinks cannot reach the patient zone or clean supplies.

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100-Infection Control Design

111 Consider using hand hygiene reminder methods (e.g., electronic devices providing automatic audible or visual reminders) to improve hand hygiene compliance.

112 Select interior finish materials for patient care areas especially high touch surfaces (e.g., floor, wall, ceiling, furniture covering, door handles) that are easy to clean, disinfect and maintain or contain antibacterial characteristics in order to minimize the risk of surface contamination.

Cost Magnitude

Your Priority

Generic Risk Estimate Med-High

Why should this be considered? (Rationale) (This cell hyperlinks to references)

Med-High

110 Select hand hygiene devices with design features (e.g., foot-operated sinks, hands-free faucets) that help prevent contamination of the fixture and recontamination of user's hands.

Safe Design Roadmap

Water splashed from sinks to nearby patient care areas have been found to increase risk of contamination and infection transmission of water-borne pathogens. Beside the location of sinks, the design of sinks themselves should be considered in order to prevent splashing into nearby patient care area. Several sink design features were recommended by research: faucet spouts not flowing directly into the drain, decreased water pressure, and physical barrier between sinks and adjacent preparatory spaces (Hota et al., 2009). It has been reported that hand hygiene devices themselves may become contaminated and play a role in pathogen transmission by contaminating the hands of staff, patients, and families (Harrison, Griffith, Ayers, & Michaels, 2003). Certain features of hand hygiene devices such as foot-operated sinks, hands-free faucets, may help reduce the likelihood of re-contamination of hands after cleaning.

Med-Low

109 Select sinks with design elements to prevent splashing into nearby areas where direct patient care is provided (including faucets, sink size/depth, water pressure, physical barrier between sinks and surrounding areas, etc.).

Highest

Sort #

What is being discussed? (Design Consideration)

Your Risk Estimate

Project Data

Risk Data: Infection Control

A Safety Risk Assessment for Healthcare Facility Environments

Copyright 2012-2015 The Center for Health Design. All Rights Reserved.

Hand hygiene is considered the single most important method of infection prevention because pathogens are often transferred via the unwashed hands of staff. Design solutions that provide reminders (electronic or visual) and/or offer automated compliance reporting have been found in multiple studies to effectively improve hand hygiene compliance (Armellino et al., 2012; Fakhry, Hanna, Anderson, Holmes, & Nathwani 2012) Research shows that the contamination of environmental surfaces may serve as a link in the chain of infection transmission. Certain surface materials have been reported to be easier to clean, disinfect, and maintain and are associated with lower risk of contamination (Anderson, Mackel, Stoler, & Mallison, 1982; Harris, Pacheco, & Lindner, 2010; Lankford et al., 2006; Noskin, Bednarz, Suriano, Reiner, & Peterson, 2000). Recent research reports indicated that antibacterial characteristics of certain surface materials may be associated with lower risk of surface contamination therefore may help prevent infection transmission (Karpanen et al., 2012; Takai et al., 2002).

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Glossary/Definitions

The Risk Component Links

What is being discussed? (Design Consideration)

How is this done? Explanations/Clarifications (How Accomplished, Reasons Against)

109 Select sinks with design elements to prevent splashing into nearby areas where direct patient care is provided (including faucets, sink size/depth, water pressure, physical barrier between sinks and surrounding areas, etc.). 110 Select hand hygiene devices with design features (e.g., foot-operated sinks, hands-free faucets) that help prevent contamination of the fixture and recontamination of user's hands.

111 Consider using hand hygiene reminder methods (e.g., electronic devices providing automatic audible or visual reminders) to improve hand hygiene compliance.

112 Select interior finish materials for patient care areas especially high touch surfaces (e.g., floor, wall, ceiling, furniture covering, door handles) that are easy to clean, disinfect and maintain or contain antibacterial characteristics in order to minimize the risk of surface contamination.

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V1.2 October2015

B = Body (required); A = Appendix (suggested); N/I or blank = not included

Location

Risk Data: Infection Control

A Safety Risk Assessment for Healthcare Facility Environments

FGI

26

100-Infection Control Design

Building category

GEN

Plumbing

GEN

Plumbing

GEN

Technology Integration

GEN

Interior Design/Finishes

B,A

B,A

27

100-Infection Control Design

115 Use building design (e.g., movable furniture) to make it easy for environmental service personnel to clean and disinfect environmental surfaces and equipment (e.g., curtains, walls, floors). 116 Select furnishings, fixtures and equipment (e.g., water faucets) that are easy to clean and maintain in order to minimize pathogen growth and prevent them from becoming pathogen reservoirs. (This consideration is also relevant under the following categories: equipment, furnishings). 117 Consider water disinfection methods if the patient population is considered at high risk for infection.

Copyright 2012-2015 The Center for Health Design. All Rights Reserved.

Safe Design Roadmap

Cost Magnitude

Your Priority

Generic Risk Estimate Med-High Med-Low Med-High

114 Identify and assess environmental fixtures (e.g., shelves, soft curtains) that likely serve as reservoirs of pathogens.

Med-High

113 Minimize dust catching through design of environmental surfaces (e.g., sloped instead of horizontal tops) for the purpose of reducing risk of contamination.

Med-High

Sort #

What is being discussed? (Design Consideration)

Your Risk Estimate

Project Data

Risk Data: Infection Control

A Safety Risk Assessment for Healthcare Facility Environments

Why should this be considered? (Rationale) (This cell hyperlinks to references) Dust particles may carry pathogens. Without proper cleaning, environmental surfaces (especially high touch objects) may catch dust and become reservoirs of pathogens. Proper environmental design that reduces the amount of dust caught on environmental surfaces may help reduce the risk of environmental surfaces becoming pathogen reservoirs thus reduce the risk of infection transmission (Williams, Singh, & Romberg, 2003). According to multiple recent epidemiological reports, without proper maintenance and cleaning, certain environmental fixtures (e.g., open water fountains, curtains) could become reservoirs of pathogens and cause outbreaks of infections (e.g.,, Palmore et al., 2009). Precautions should be taken to reduce the risk involved with environmental features known to be potential reservoirs of pathogens. Without proper cleaning, environmental surfaces (especially high touch objects) often become reservoirs of pathogens. Environmental design may facilitate the cleaning of high touch objects (e.g., door handles, toilet handles, hand rails) thus reduce environmental contamination and reduce the risk of infection transmission (Williams et al., 2003). There are reports about infections associated with fixtures and equipment (e.g., certain types of water faucets) (Sydnor et al., 2012). Fixtures and equipment that are easy to clean and maintain may be associated with lower chance of becoming pathogen reservoirs and lower risk of contributing to infection transmission.

Research has found different levels of effectiveness of various water disinfection methods in preventing or controlling various types of water contamination and outbreaks of waterborne infections (Modol et al., 2007). Proper water disinfection methods should be considered when designing plumbing systems.

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Sort #

Glossary/Definitions

The Risk Component Links

What is being discussed? (Design Consideration)

How is this done? Explanations/Clarifications (How Accomplished, Reasons Against)

113 Minimize dust catching through design of environmental surfaces (e.g., sloped instead of horizontal tops) for the purpose of reducing risk of contamination.

114 Identify and assess environmental fixtures (e.g., shelves, soft curtains) that likely serve as reservoirs of pathogens.

115 Use building design (e.g., movable furniture) to make it easy for environmental service personnel to clean and disinfect environmental surfaces and equipment (e.g., curtains, walls, floors). 116 Select furnishings, fixtures and equipment (e.g., water faucets) that are easy to clean and maintain in order to minimize pathogen growth and prevent them from becoming pathogen reservoirs. (This consideration is also relevant under the following categories: equipment, furnishings).

B = Body (required); A = Appendix (suggested); N/I or blank = not included

Location

Risk Data: Infection Control

A Safety Risk Assessment for Healthcare Facility Environments

FGI

28

100-Infection Control Design

Building category

GEN

Interior Design/Finishes

GEN

Furnishings

GEN

Furnishings

GEN

Plumbing

B

GEN

Plumbing

B,A

B

117 Consider water disinfection methods if the patient population is considered at high risk for infection.

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100-Infection Control Design

118 Include control measures (elimination, disinfecting equipment/features to address environmental infection risks and reduce infection risk related to environmental furnishings and fixtures (e.g., shelves, soft curtains). (This consideration is also relevant under the following categories: equipment, plumbing). 119 Collaboratively review with Infection Prevention, Facilities Management and the Mechanical Design issues related to infection prevention, reliability and maintainability of HVAC systems for each area affected by this project. Considerations include:

Safe Design Roadmap

Cost Magnitude

Your Priority

Generic Risk Estimate Med-Low

Sort #

What is being discussed? (Design Consideration)

Your Risk Estimate

Project Data

Risk Data: Infection Control

Why should this be considered? (Rationale) (This cell hyperlinks to references) According to multiple recent epidemiological reports, without proper maintenance and cleaning, certain environmental fixtures (e.g., fountains, curtains) could become reservoirs of pathogens and cause outbreaks of infections (e.g.,, Palmore et al., 2009). Certain infection control measures including equipment and design characteristics that address contamination risks may help reduce the contamination.

Research indicates that HVAC system design elements (including location of ventilation grilles, air pressure difference between nearby spaces to prevent leakage of contaminated air, type and location of air filters, air disinfection, ventilation rates, etc.) significantly impacts a HVAC system’s effectiveness of reducing air contamination and improving air hygiene in healthcare settings (Beggs, Kerr, Noakes, Hathway, & Sleigh, 2008; Menzies, Fanning, Yuan, & FitzGerald, 2000)

zones to allow environmental control flexibility

Med-High

for critical areas) temperature and humidity

A Safety Risk Assessment for Healthcare Facility Environments

intended use of space unique environmental conditions (e.g., entryways, protection in food service area for pest control, patientcentric environmental control in burn, ICU or neonatal areas)

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Sort #

Glossary/Definitions

The Risk Component Links

What is being discussed? (Design Consideration)

How is this done? Explanations/Clarifications (How Accomplished, Reasons Against)

118 Include control measures (elimination, disinfecting equipment/features to address environmental infection risks and reduce infection risk related to environmental furnishings and fixtures (e.g., shelves, soft curtains). (This consideration is also relevant under the following categories: equipment, plumbing).

B = Body (required); A = Appendix (suggested); N/I or blank = not included

Location

Risk Data: Infection Control

A Safety Risk Assessment for Healthcare Facility Environments

FGI

30

100-Infection Control Design

Building category

GEN

Furnishings

B

GEN

Mechanical (HVAC)/Electrical

B

119 Collaboratively review with Infection Prevention, Facilities Management and the Mechanical Design issues related to infection prevention, reliability and maintainability of HVAC systems for each area affected by this project. Considerations include: for critical areas) temperature and humidity zones to allow environmental control flexibility intended use of space unique environmental conditions (e.g., entryways, protection in food service area for pest control, patientcentric environmental control in burn, ICU or neonatal areas)

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100-Infection Control Design

Cost Magnitude

Your Priority

Generic Risk Estimate Med-High

124 Provide adequate monitoring equipment (e.g., moisture and leakage alarm) to monitor possible environment hazards (e.g., dampness) in HVAC in the building lifecycle.

Med-High

123 Put in place proper monitoring devices to ensure that the ventilation system works as designed throughout its whole lifecycle.

Research shows that the filtered air is often re-contaminated after being filtered with central filters (located inside main air ducts) and before flowing into healthcare spaces. Peripheral filters (located at the openings of ducts) were found to make the air flowing into healthcare spaces cleaner (Crimi et al., 2006). HVAC equipment can be contaminated and subsequently contaminate the air entering into healthcare spaces (Lutz, Jin, Rinaldi, Wickes, & Huycke, 2003). Studies found that certain HVAC components with antibacterial characteristics were associated with lower risk of HVAC system contamination and air contamination (Schmidt et al., 2012).

Med-High

122 Select the most effective ventilation method among various design options (e.g., conventional, laminar, nonaspirating, displacement) in keeping the air in OR clean based on simulation or other studies.

Why should this be considered? (Rationale) (This cell hyperlinks to references)

Research found that the effectiveness of different OR ventilation methods (e.g., conventional, laminar, non-aspirating, displacement) varies significantly depending on different surgical procedures and OR layout (Memarzadeh & Manning, 2002). To minimize the risk of infection contracted in OR, the most effective OR ventilation method should be selected.

Med-High

120 Optimize the location of air filters (including highefficiency particulate air [HEPA] filters) within the ventilation system (e.g., inside main air ducts vs. at the openings of ducts) to minimize the risk of recontamination of filtered clean air. 121 Select HVAC equipment containing antibacterial characteristics that reduce the risk and degree of contamination.

Safe Design Roadmap

Research has found cases in which the ventilation systems may not work as designed (e.g., air flowing from negative pressure rooms to other spaces) and the deficiency in ventilation may cause infection outbreaks (Fraser et al., 1993). Proper monitoring, commissioning and maintenance should be done in order to optimize the performance of ventilation systems.

Med-High

Sort #

What is being discussed? (Design Consideration)

Your Risk Estimate

Project Data

Risk Data: Infection Control

A Safety Risk Assessment for Healthcare Facility Environments

Research indicates that environmental hazards such as dampness in the HVAC system may result in contamination during the life cycle of a building (Lutz et al., 2003). It's essential to proactively monitor the possible environmental hazards (e.g., dampness) so that proper maintenance and other contamination prevention/reduction methods can be implemented to eliminate the hazards thus reduce risk of infection transmission.

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Location Key: GEN = General Consideration; OL = Overall Layout; IP = Inpatient; D&T = Diagnostic & Treatment; Rx = Pharmacy; ED = Emergency Department; HIM = Med. Records/Health Information Mgmt; OR = Operating; SEC = Seclusion

Sort #

Glossary/Definitions

The Risk Component Links

What is being discussed? (Design Consideration)

How is this done? Explanations/Clarifications (How Accomplished, Reasons Against)

120 Optimize the location of air filters (including highefficiency particulate air [HEPA] filters) within the ventilation system (e.g., inside main air ducts vs. at the openings of ducts) to minimize the risk of recontamination of filtered clean air. 121 Select HVAC equipment containing antibacterial characteristics that reduce the risk and degree of contamination.

122 Select the most effective ventilation method among various design options (e.g., conventional, laminar, nonaspirating, displacement) in keeping the air in OR clean based on simulation or other studies. 123 Put in place proper monitoring devices to ensure that the ventilation system works as designed throughout its whole lifecycle.

124 Provide adequate monitoring equipment (e.g., moisture and leakage alarm) to monitor possible environment hazards (e.g., dampness) in HVAC in the building lifecycle.

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B = Body (required); A = Appendix (suggested); N/I or blank = not included

Location

Risk Data: Infection Control

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FGI

32

100-Infection Control Design

Building category

GEN

Mechanical (HVAC)/Electrical

B

GEN

Mechanical (HVAC)/Electrical

B,A

OR

Mechanical (HVAC)/Electrical

B

GEN

Mechanical (HVAC)/Electrical

B

GEN

Mechanical (HVAC)/Electrical

B,A

33

100-Infection Control Design

126 Identify potential major sources of airborne, waterborne and other contaminants such as a construction site within or close to the patient care areas in operation. (This consideration is also relevant under the following categories: building layout, unit layout.) 127 Provide for appropriate environmental disinfection methods (e.g., HEPA filters, barriers, isolated HVAC system) to control the contamination from major sources of contaminants such as a construction site. (This consideration is also relevant under the following categories: building layout, unit layout.) Refer to the ICRA Matrix for more detailed risk assessment considerations related to construction and renovation activities according to ICRA-defined construction type and patient risk.

Safe Design Roadmap

Cost Magnitude

Your Priority

Generic Risk Estimate Med-High Med-High

125 Through building design (e.g., adequate access opening), allow easy access to properly maintain or replace contaminated HVAC and other building components in order to mitigate potential environmental hazards (e.g., contamination due to dampness) in the building lifecycle.

Why should this be considered? (Rationale) (This cell hyperlinks to references) Research indicates that environmental hazards such as dampness in the HVAC system may result in contamination during the life cycle of a building (Lutz et al., 2003). It's essential to proactively monitor the possible environmental hazards and identify methods of controlling contamination. After the identification of potential problems, easy access would be very important to facilitate necessary maintenance or replacement to mitigate the environmental hazards. Research indicates that construction sites, as well as other building activities or components, may become a source of contaminants and cause infection outbreaks (Barnes & Rogers, 1989).

Research has found certain disinfection methods such as HEPA filtration are effective in controlling major sources of contaminants such as construction sites (Barnes & Rogers, 1989). Med-High

Sort #

What is being discussed? (Design Consideration)

Your Risk Estimate

Project Data

Risk Data: Infection Control

A Safety Risk Assessment for Healthcare Facility Environments

Copyright 2012-2015 The Center for Health Design. All Rights Reserved.

The ICRA Matrix includes detailed steps for identifying the appropriate environmental disinfection methods based on construction type and patient risk level.

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Sort #

Glossary/Definitions

The Risk Component Links

What is being discussed? (Design Consideration)

How is this done? Explanations/Clarifications (How Accomplished, Reasons Against)

B = Body (required); A = Appendix (suggested); N/I or blank = not included

Location

Risk Data: Infection Control

A Safety Risk Assessment for Healthcare Facility Environments

FGI

34

100-Infection Control Design

Building category

125 Through building design (e.g., adequate access opening), allow easy access to properly maintain or replace contaminated HVAC and other building components in order to mitigate potential environmental hazards (e.g., contamination due to dampness) in the building lifecycle.

GEN

126 Identify potential major sources of airborne, waterborne and other contaminants such as a construction site within or close to the patient care areas in operation. (This consideration is also relevant under the following categories: building layout, unit layout.)

GEN Site Optimization

B

GEN Site Optimization

B,A

127 Provide for appropriate environmental disinfection methods (e.g., HEPA filters, barriers, isolated HVAC system) to control the contamination from major sources of contaminants such as a construction site. (This consideration is also relevant under the following categories: building layout, unit layout.) Refer to the ICRA Matrix for more detailed risk assessment considerations related to construction and renovation activities according to ICRA-defined construction type and patient risk.

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V1.2 October2015

Mechanical (HVAC)/Electrical

B,A

35

100-Infection Control Design

128 Minimize the needs of OR door openings necessary to conduct routine work through OR suite design (e.g., supply storage in OR, wireless consultation/communication). (This consideration is also relevant under the following category: room layout.)

Copyright 2012-2015 The Center for Health Design. All Rights Reserved.

Safe Design Roadmap

Cost Magnitude

Your Priority

Generic Risk Estimate Med-High

Sort #

What is being discussed? (Design Consideration)

Your Risk Estimate

Project Data

Risk Data: Infection Control

A Safety Risk Assessment for Healthcare Facility Environments

Why should this be considered? (Rationale) (This cell hyperlinks to references) Research has found that the number of door openings during surgical procedures may generate disturbances to air flows and cause increase of the air contamination level in OR's (Andersson, Bergh, Karlsson, Eriksson, & Nilsson, 2012). The need for OR door openings during surgical procedures may be reduced through building design (e.g., locating certain supplies within the OR, wireless consultation). This in turn may help reduce the risk of infections for OR patients.

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Sort #

Glossary/Definitions

The Risk Component Links

What is being discussed? (Design Consideration)

How is this done? Explanations/Clarifications (How Accomplished, Reasons Against)

128 Minimize the needs of OR door openings necessary to conduct routine work through OR suite design (e.g., supply storage in OR, wireless consultation/communication). (This consideration is also relevant under the following category: room layout.)

Copyright 2012-2015 The Center for Health Design. All Rights Reserved.

B = Body (required); A = Appendix (suggested); N/I or blank = not included

Location

Risk Data: Infection Control

A Safety Risk Assessment for Healthcare Facility Environments

OR

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FGI

36

100-Infection Control Design

Building category

Unit Layout

37

Med Safety Risk Data

Home

Design Considerations: Medication Safety

A Safety Risk Assessment for Healthcare Facility Environments

Safe Design Roadmap

Project Data

The Risk Component Links

Glossary/Definitions

Medication errors, the most common medical errors, may adversely impact healthcare outcomes, as indicated in the Institute of Medicine (IOM) reports such as "Crossing the Quality Chasm" and "To Err is Human." It was estimated that between 380,000 and 450,000 preventable adverse drug events (ADEs) occurred annually in U.S. hospitals. ADEs refer to any injuries resulting from medication use, including physical harm, mental harm or loss of function. ADEs have been found to directly contribute to increased morbidity and mortality, prolonged hospitalizations and higher costs of care. Consider the patient risk groups (spaces) to be affected and the potential outcomes. Is the likelihood rare or almost certain? Is the consequence negligible or minor injury or a sentinel event?

The number and locations of medication safety zones (MSZs) should be clearly identified. A MSZ is defined in the literature as a critical area where medications are prescribed, orders are entered into a computer or transcribed onto paper documents, and where medications are prepared, dispensed or administered. Examples include work surfaces of medication carts, nursing units, any location where prescribing decisions are made, work surface of an automated medication dispensing device, pharmacy and patient bedside. Identifying these zones early on is critical to developing design solutions.

A panel of experts created a generic level of risk, but this should be considered with respect to your own organization and patient demographic. You might consider a typical “heat map” of risk throughout your decision process. A sample is shown.

Consequence

An understanding of historical data can help identify and assess current issues around medication errors and define how operational and physical environment conditions may overlap. A healthcare organization should evaluate its own historical data on medication errors to identify existing physical environment conditions (e.g., lighting levels, workspace organization, etc.), that could be related to medication errors in both inpatient and outpatient areas. Evaluate historical data to ascertain all conditions that contribute to medication errors in your facility.

Likelihood Rare

Unlikely

Possible

Sentinel event Partial disability Medical treatment First aid No injury or disability

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Likely

Almost Certain

38

Med Safety Risk Data

Home

Design Considerations: Medication Safety

Safe Design Roadmap

Project Data

Evaluate historical data to ascertain all conditions (e.g., service type, patient populations) that contribute to harm in both inpatient and outpatient areas.

Location/Unit Type

Medication safety type (e.g., error, sticks)/rate

Copyright 2012-2015 The Center for Health Design. All Rights Reserved.

A Safety Risk Assessment for Healthcare Facility Environments

The Risk Component Links

Glossary/Definitions

Past performance does not guarantee future results, but this may help identify the likelihood of events specific to the organization. Are there patterns of vulnerability?

Subject Matter Expert Consulted (Name)

V1.2 October2015

Title/Role

Data Source

39

200-Medication Safety Design

Cost Magnitude

Generic Risk Estimate Med-Low

Why should this be considered? (Rationale) (This cell hyperlinks to references) Refer to the functional and operational program provided for the project to understand the work tasks and workflows that are anticipated for the space (Grissinger, 2012; United States Pharmacopeia (USP), 2010). It is important that the design enables the fulfillment of the defined tasks in the most efficient manner possible. This is linked to increased efficiency and reduced fatigue, which can have an impact on errors. Empirical evidence on specific strategies to improve efficiency is lacking.

Med-High

200 Clearly identify the purpose, associated work tasks and workflow in the functional and operational program for each medication safety zone in order to design ergonomic and efficient workspaces. (This consideration is also relevant under the following category: room layout.)

Safe Design Roadmap

There is high probability of interruptions occurring when medication preparation activities take place near or in a circulation zone (such as a corridor). Medication safety zones should be located away from areas with heavy staff, patient or family activity. Research supports that sensory/perceptual interference (e.g., interruption by a co-worker) can impair error-free performance due to the cognitive load of switching tasks (i.e. time to reorient to the task after being interrupted) or prospective memory failure (i.e. forgetting where you left off). Being interrupted can result in both procedural failures (e.g., failure to read labels, check patient ID or record administration on medication chart) and clinical errors (e.g., wrong drug, dose, formulation, strength) (Chaudhury, Mahmood, & Valente, 2009; E. A. Flynn et al., 1999; L. Flynn, Liang, Dickson, Xie, & Suh, 2012; Mahmood, Chaudhury, & Valente, 2011).

Med-High

Sort #

What is being discussed? (Design Consideration)

Your Risk Estimate Your Priority

Project Data

Risk Data: Medication Safety

A Safety Risk Assessment for Healthcare Facility Environments

When medication safety zones are located in spaces where other activities also take place (such as a clean utilities room), the additional traffic in the room can increase the potential of distractions and interruptions. Research supports that sensory/perceptual interference (e.g., interruption by a co-worker) can impair error-free performance due to the cognitive load of switching tasks (i.e. time to reorient to the task after being interrupted) or prospective memory failure (i.e. forgetting where you left off). Being interrupted can result in both procedural failures (e.g., failure to read labels, check patient ID or record administration on medication chart) and clinical errors (e.g., wrong drug, dose, formulation, strength) (Grissinger, 2012; United States Pharmacopeia (USP), 2010).

201 Locate the medication safety zones out of circulation paths to minimize distraction and interruption. (This consideration is also relevant under the following category: room layout.)

202 Limit traffic through the medication safety zone. (This consideration is also relevant under the following category: room layout)

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Location Key: GEN = General Consideration; OL = Overall Layout; IP = Inpatient; D&T = Diagnostic & Treatment; Rx = Pharmacy; ED = Emergency Department; HIM = Med. Records/Health Information Mgmt; OR = Operating; SEC = Seclusion

Sort #

Glossary/Definitions

The Risk Component Links

What is being discussed? (Design Consideration)

How is this done? Explanations/Clarifications (How Accomplished, Reasons Against)

200 Clearly identify the purpose, associated work tasks and workflow in the functional and operational program for each medication safety zone in order to design ergonomic and efficient workspaces. (This consideration is also relevant under the following category: room layout.)

B = Body (required); A = Appendix (suggested); N/I or blank = not included

Location

Risk Data: Medication Safety

A Safety Risk Assessment for Healthcare Facility Environments

FGI

40

200-Medication Safety Design

Building category

GEN

Unit Layout

Q

OL

Unit Layout

B

OL

Unit Layout

A

201 Locate the medication safety zones out of circulation paths to minimize distraction and interruption. (This consideration is also relevant under the following category: room layout.)

202 Limit traffic through the medication safety zone. (This consideration is also relevant under the following category: room layout)

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200-Medication Safety Design

Cost Magnitude

Generic Risk Estimate Med-Low

In situations where medication safety zones have to be located in areas with heavy staff, patient or family activity, physical or visual barriers such as wall panels will help to minimize distractions and chances of being interrupted. Research supports that sensory/perceptual interference (e.g., interruption by a co-worker) can impair error-free performance due to the cognitive load of switching tasks (i.e. time to reorient to the task after being interrupted) or prospective memory failure (i.e. forgetting where you left off). Being interrupted can result in both procedural failures (e.g., failure to read labels, check patient ID or record administration on medication chart) and clinical errors (e.g., wrong drug, dose, formulation, strength) (Anthony, Wiencek, Bauer, Daly, & Anthony, 2010a; Coiera, 2012; Pluyter, Buzink, Rutkowski, & Jakimowicz, 2010). When medication safety zones are located adjacent to high traffic areas (e.g., nursing station, corridor), the potential for interruptions and distractions increases. Consider adjacencies while locating the medication safety zone. Research supports that sensory/perceptual interference (e.g., interruption by a co-worker) can impair error-free performance due to the cognitive load of switching tasks (i.e. time to reorient to the task after being interrupted) or prospective memory failure (i.e. forgetting where you left off). Being interrupted can result in both procedural failures (e.g., failure to read labels, check patient ID or record administration on medication chart) and clinical errors (e.g., wrong drug, dose, formulation, strength) (Pluyter et al., 2010). In many areas of the hospital minimizing technological sources of distraction, like overhead paging systems, may not be feasible since they may relate to the communication of urgent situations. In the case of medication preparation spaces, best practice recommendations suggest that Interruptions and distractions be minimized by providing staff with the ability to control and manage their exposure to external disturbances by access to a medication preparation room, or mobile carts within workspaces.

204 Carefully consider adjacencies and mitigate potential sources of distraction in the medication safety zone (e.g., auditory and/or visual).

205 Provide a separate medication preparation room for staff to conduct medication-related tasks with minimum interruption/distraction.

Why should this be considered? (Rationale) (This cell hyperlinks to references)

Med-Low

203 Use visual and/or physical barriers to reduce distractions and interruptions, without compromising the main clinical function in the medication safety zone.

Safe Design Roadmap

Med-High

Sort #

What is being discussed? (Design Consideration)

Your Risk Estimate Your Priority

Project Data

Risk Data: Medication Safety

A Safety Risk Assessment for Healthcare Facility Environments

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Location Key: GEN = General Consideration; OL = Overall Layout; IP = Inpatient; D&T = Diagnostic & Treatment; Rx = Pharmacy; ED = Emergency Department; HIM = Med. Records/Health Information Mgmt; OR = Operating; SEC = Seclusion

Sort #

Glossary/Definitions

The Risk Component Links

What is being discussed? (Design Consideration)

How is this done? Explanations/Clarifications (How Accomplished, Reasons Against)

B = Body (required); A = Appendix (suggested); N/I or blank = not included

Location

Risk Data: Medication Safety

A Safety Risk Assessment for Healthcare Facility Environments

FGI

42

200-Medication Safety Design

Building category

203 Use visual and/or physical barriers to reduce distractions and interruptions, without compromising the main clinical function in the medication safety zone. OL

Unit Layout

OL

Unit Layout

OL

Unit Layout

A

204 Carefully consider adjacencies and mitigate potential sources of distraction in the medication safety zone (e.g., auditory and/or visual).

205 Provide a separate medication preparation room for staff to conduct medication-related tasks with minimum interruption/distraction.

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V1.2 October2015

A

43

200-Medication Safety Design

207 Standardize the design for clinically similar areas in the workspace, with regard to medication related equipment, information technology, supporting materials (e.g., labels, medication instructions) required to support the workflow for those tasks described in the functional program. (This consideration is also relevant under the following category: unit layout.) 208 Provide a visible sharps container accessible to personnel within the medication safety zone. (This consideration is also relevant under the following category: unit layout.)

Copyright 2012-2015 The Center for Health Design. All Rights Reserved.

Safe Design Roadmap

Cost Magnitude

Generic Risk Estimate Med-High Med-High

206 Provide space for the key tasks identified in the functional program to reflect the number of staff expected to work in the medication safety zone. (This consideration is also relevant under the following category: unit layout.)

Med-High

Sort #

What is being discussed? (Design Consideration)

Your Risk Estimate Your Priority

Project Data

Risk Data: Medication Safety

A Safety Risk Assessment for Healthcare Facility Environments

Why should this be considered? (Rationale) (This cell hyperlinks to references) The space provided for the medication safety zone should be able to accommodate the number of workers and the range of tasks, while also adhering to the recommended design features to decrease interruptions and distractions, mitigate noise, and provide the appropriate task lighting and workspace organization (Grissinger, 2012; United States Pharmacopeia (USP), 2010). This is linked to increased efficiency and reduced fatigue, which can have an impact on errors. Empirical evidence on specific strategies to improve efficiency is lacking. Medication Safety Zones can occur in multiple locations through the facility. Design researchers argue that standardization of patient-care environments and equipment can reduce cognitive load on the staff and help to increase efficiency and reduce errors. This premise can be extended to the organization of the work space and the placement of items in relation to each other. Standardization of the medication safety zone should be approached within the context of standards used within the system. If no standards exist for medication safety zone in the system, effort should be made to set standards. Although not strictly an errors issue, careful design of sharps containers in medication safety zone pertains to the overall construct of medication safety. Recommendations include: a clear view of the opening to help workers dispose of sharps accurately (i.e. to view how full the container is, and to see if there are any sharps near or coming through the opening); consideration to reduce surface contact with sharps containers; location so as to avoid excessive reaching or awkward postures (i.e. below shoulder height of the shortest employee, within forward reach when using a pinch grip, and unobstructed by any other equipment or furniture); and consideration for safe access for healthcare workers while reducing access by young children or individuals with cognitive impairment.

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Location Key: GEN = General Consideration; OL = Overall Layout; IP = Inpatient; D&T = Diagnostic & Treatment; Rx = Pharmacy; ED = Emergency Department; HIM = Med. Records/Health Information Mgmt; OR = Operating; SEC = Seclusion

Sort #

Glossary/Definitions

The Risk Component Links

What is being discussed? (Design Consideration)

How is this done? Explanations/Clarifications (How Accomplished, Reasons Against)

206 Provide space for the key tasks identified in the functional program to reflect the number of staff expected to work in the medication safety zone. (This consideration is also relevant under the following category: unit layout.)

207 Standardize the design for clinically similar areas in the workspace, with regard to medication related equipment, information technology, supporting materials (e.g., labels, medication instructions) required to support the workflow for those tasks described in the functional program. (This consideration is also relevant under the following category: unit layout.)

B = Body (required); A = Appendix (suggested); N/I or blank = not included

Location

Risk Data: Medication Safety

A Safety Risk Assessment for Healthcare Facility Environments

FGI

44

200-Medication Safety Design

Building category

OL

Room Layout

OL

Room Layout

IP

Room Layout

208 Provide a visible sharps container accessible to personnel within the medication safety zone. (This consideration is also relevant under the following category: unit layout.)

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V1.2 October2015

A

45

200-Medication Safety Design

Cost Magnitude

Generic Risk Estimate Lowest

It is important during medication administration for critical verbal information to be heard. At the same time it is not feasible or desirable to eliminate noise entirely. The Acoustical Design Criteria in the Guidelines provides information for layout, selection of materials, HVAC and building systems design to support well designed acoustical environments.

211 Use sound-absorbing materials (when permitted by infection control guidelines) to reduce noise levels in the medication safety zone.

It is important during medication administration for critical verbal information to be heard. At the same time it is not feasible or desirable to eliminate noise entirely (white noise may sometimes help to mask undesirable sounds).

212 Design the medication safety zone (MSZ) to enable the clear visualization (labeling information) and organization of medication related products in the MSZ work space (e.g., use of adjustable fixtures, drawer and storage design, counter height and designs to minimize work surface clutter). (This consideration is also relevant under the following category: interior design.) 213 Provide well-organized storage spaces/shelves at a height to enable visual differentiation and with a degree of separation to enable the selection of the correct medication. (This consideration is also relevant under the following category: room layout.)

Med-High

210 Consider the different factors that may impact the sound quality and noise levels in medication safety zones including layout, selection of materials and HVAC and building system design. (This consideration is also relevant under the following category: HVAC.)

Med-Low

Why should this be considered? (Rationale) (This cell hyperlinks to references) Research also shows that simple use of visual cues, such as a demarcation on the floor, can help to define a "No Interruption Zone", especially in areas where it may not be possible to limit traffic directly (Anthony, Wiencek, Bauer, Daly, & Anthony, 2010b).

Med-High

209 Use visual clues such as a change in floor color to delineate a medication safety zone/ No Interruption Zone.

Safe Design Roadmap

Med-High

Sort #

What is being discussed? (Design Consideration)

Your Risk Estimate Your Priority

Project Data

Risk Data: Medication Safety

A Safety Risk Assessment for Healthcare Facility Environments

Copyright 2012-2015 The Center for Health Design. All Rights Reserved.

It is important that the medication safety zone is ergonomic and well organized to enable staff to easily and accurately perform tasks related to medication preparation. This might include paying attention to drawer and storage design, lighting design, counter height, use of adjustable fixtures and workspace design to support workflow and minimize surface clutter.

A pressing concern in medication errors is the clutter associated with the storage of different medications/drugs. Research shows that more dispensing errors occurred when medication storage containers were placed in a cluttered fashion with less than an inch of separation between distinct drugs, making it difficult to differentiate between each item (E. Flynn, Dorris, Holman, Carnahan, & Barker, 2002).

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Location Key: GEN = General Consideration; OL = Overall Layout; IP = Inpatient; D&T = Diagnostic & Treatment; Rx = Pharmacy; ED = Emergency Department; HIM = Med. Records/Health Information Mgmt; OR = Operating; SEC = Seclusion

Sort #

Glossary/Definitions

The Risk Component Links

What is being discussed? (Design Consideration)

How is this done? Explanations/Clarifications (How Accomplished, Reasons Against)

209 Use visual clues such as a change in floor color to delineate a medication safety zone/ No Interruption Zone.

B = Body (required); A = Appendix (suggested); N/I or blank = not included

Location

Risk Data: Medication Safety

A Safety Risk Assessment for Healthcare Facility Environments

FGI

46

200-Medication Safety Design

Building category

OL

Interior Design/Finishes

210 Consider the different factors that may impact the sound quality and noise levels in medication safety zones including layout, selection of materials and HVAC and building system design. (This consideration is also relevant under the following category: HVAC.)

OL

Interior Design/Finishes

B

211 Use sound-absorbing materials (when permitted by infection control guidelines) to reduce noise levels in the medication safety zone.

OL

Interior Design/Finishes

A

OL

Furnishings

A

OL

Furnishings

A

212 Design the medication safety zone (MSZ) to enable the clear visualization (labeling information) and organization of medication related products in the MSZ work space (e.g., use of adjustable fixtures, drawer and storage design, counter height and designs to minimize work surface clutter). (This consideration is also relevant under the following category: interior design.) 213 Provide well-organized storage spaces/shelves at a height to enable visual differentiation and with a degree of separation to enable the selection of the correct medication. (This consideration is also relevant under the following category: room layout.)

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200-Medication Safety Design

216 Provide task lighting at the patient point of care so that visual confirmation of the correct patient (reading arm band), medication and dosage and administration site is not compromised. 217 Position or shield lighting so there is minimum glare on the computer monitor that may make it difficult to read the screen accurately.

Cost Magnitude

Generic Risk Estimate Med-High

Critical visual tasks related to medication administration include reading small print on labels and handwritten prescriptions, and inspecting medication dosage forms. Inadequate lighting during such tasks can lead to errors (Buchanan, Barker, Gibson, Jiang, & Pearson, 1991; Grissinger, 2012; United States Pharmacopeia (USP), 2010). The United States Pharmacopeia and The National Formulary (USP–NF) General Chapter lists the lighting levels needed for specific critical visual tasks, which can serve as a guide for required lighting levels.

Highest

215 Provide the USP-NF-recommended task lighting for medication preparation and administration on the mobile medication-dispensing carts, when used.

Why should this be considered? (Rationale) (This cell hyperlinks to references)

Critical visual tasks related to medication administration include reading small print on labels and handwritten prescriptions, and inspecting medication dosage forms (Buchanan et al., 1991; Grissinger, 2012; United States Pharmacopeia (USP), 2010). Inadequate lighting during such tasks can lead to errors. Having focused task lighting (with appropriate illumination levels) on mobile medication-dispensing carts can minimize the risk of errors due to compromised vision.

Med-High

214 Specify USP-NF-specific lighting levels for the different tasks in the medication safety zone including: (i) Designated computer entry and handwritten orderprocessing locations, (ii) Pharmacy medication filling and checking, (iii) Pharmacy patient counseling, (iv) Sterile compounding and preparation, (v) Storeroom for pharmacy medication, (vi) Medication preparation area, (vii) Medication administration work areas (including the patient room).

Safe Design Roadmap

Having focused task lighting (with appropriate illumination levels) can minimize the risk of errors due to compromised vision. This is particularly important at the patient point of care- where the medication is administered to allow visual confirmation of the correct patient (reading arm band), and medication.

Highest

Sort #

What is being discussed? (Design Consideration)

Your Risk Estimate Your Priority

Project Data

Risk Data: Medication Safety

A Safety Risk Assessment for Healthcare Facility Environments

Ability to read information from a computer screen is a key component of medication administration. Although there is no research linking glare on the computer screen to error, it follows the fundamental principle of enabling critical visual tasks.

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Location Key: GEN = General Consideration; OL = Overall Layout; IP = Inpatient; D&T = Diagnostic & Treatment; Rx = Pharmacy; ED = Emergency Department; HIM = Med. Records/Health Information Mgmt; OR = Operating; SEC = Seclusion

Sort #

Glossary/Definitions

The Risk Component Links

What is being discussed? (Design Consideration)

How is this done? Explanations/Clarifications (How Accomplished, Reasons Against)

214 Specify USP-NF-specific lighting levels for the different tasks in the medication safety zone including: (i) Designated computer entry and handwritten orderprocessing locations, (ii) Pharmacy medication filling and checking, (iii) Pharmacy patient counseling, (iv) Sterile compounding and preparation, (v) Storeroom for pharmacy medication, (vi) Medication preparation area, (vii) Medication administration work areas (including the patient room).

B = Body (required); A = Appendix (suggested); N/I or blank = not included

Location

Risk Data: Medication Safety

A Safety Risk Assessment for Healthcare Facility Environments

FGI

48

200-Medication Safety Design

Building category

Rx

Lighting

B

GEN

Lighting

B

GEN

Lighting

B

GEN

Lighting

A

215 Provide the USP-NF-recommended task lighting for medication preparation and administration on the mobile medication-dispensing carts, when used.

216 Provide task lighting at the patient point of care so that visual confirmation of the correct patient (reading arm band), medication and dosage and administration site is not compromised. 217 Position or shield lighting so there is minimum glare on the computer monitor that may make it difficult to read the screen accurately.

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200-Medication Safety Design

221 Design spaces for the integration of information technology required for medication safety (e.g., use of barcode readers, CPOE, etc.).

Cost Magnitude

Generic Risk Estimate Med-Low

220 If an automated dispensing system for medication administration is being implemented, consider associated workflows and design of the medication safety zone.

A narrow focus on adequate illumination and task lighting in areas identified for critical visual tasks may inadvertently result in extremely dark adjacent areas. This sudden contrast between dark and bright areas can cause issues with adjusting vision, and therefore visual acuity. Best practice recommendations suggest the use of transitional lighting to avoid this situation.

Med-Low

219 Specify lighting fixtures that can be easily cleaned and maintained.

Why should this be considered? (Rationale) (This cell hyperlinks to references)

For a lighting fixture to provide required illumination levels it is important that they are maintained at recommended levels. The selection of the appropriate light fixture type and quantity should take into account the effects of light loss from lamp lumen depreciation (LLD) and luminaire dirt depreciation (LDD).

Med-High

218 Provide transitional lighting for those medication safety zones found in patient care areas to avoid sudden contrasts between dark and bright areas.

Safe Design Roadmap

Studies show that automated dispensing system improved the efficiency of drug distribution over the traditional unit dose cassette-exchange system. While not directly related to the physical environment, considerations for an automated dispensing system could impact workflows and subsequently the design of the MSZ (Schwarz & Brodwy, 1995).

Med-Low

Sort #

What is being discussed? (Design Consideration)

Your Risk Estimate Your Priority

Project Data

Risk Data: Medication Safety

A Safety Risk Assessment for Healthcare Facility Environments

Research shows appropriate increases in the use of information technology in health care, (i.e. the introduction of clinical decision support and better linkages in/among systems, resulting in process simplification) could result in substantial improvement in patient safety (Bates et al., 2001; Chaudhury et al., 2009; Mahmood et al., 2011; Poon et al., 2006). IT has specific implications for design relating to electrical outlets, cables, and provision for equipment required for medication safety.

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Location Key: GEN = General Consideration; OL = Overall Layout; IP = Inpatient; D&T = Diagnostic & Treatment; Rx = Pharmacy; ED = Emergency Department; HIM = Med. Records/Health Information Mgmt; OR = Operating; SEC = Seclusion

Sort #

Glossary/Definitions

The Risk Component Links

What is being discussed? (Design Consideration)

How is this done? Explanations/Clarifications (How Accomplished, Reasons Against)

218 Provide transitional lighting for those medication safety zones found in patient care areas to avoid sudden contrasts between dark and bright areas.

219 Specify lighting fixtures that can be easily cleaned and maintained.

220 If an automated dispensing system for medication administration is being implemented, consider associated workflows and design of the medication safety zone.

B = Body (required); A = Appendix (suggested); N/I or blank = not included

Location

Risk Data: Medication Safety

A Safety Risk Assessment for Healthcare Facility Environments

V1.2 October2015

Building category

IP

Lighting

GEN

Lighting

GEN

Technology Integration

A

GEN

Technology Integration

A

221 Design spaces for the integration of information technology required for medication safety (e.g., use of barcode readers, CPOE, etc.).

Copyright 2012-2015 The Center for Health Design. All Rights Reserved.

FGI

50

200-Medication Safety Design

51

200-Medication Safety Design

223 Identify and provide the space needed for medication associated equipment (e.g., barcode reader, mobile medication cart, etc.) and safety technology (e.g., CPOE) in inpatient and outpatient medication safety zones. (This consideration is also relevant under the following category: room layout.) 224 Enable ready access to clinical information, both patient specific and medication related, through the organization of the medication safety zone (MSZ) workspace.

Copyright 2012-2015 The Center for Health Design. All Rights Reserved.

Safe Design Roadmap

Cost Magnitude

Generic Risk Estimate Med-High Med-High

222 Design spaces to enable point of care barcode verification to reduce errors in the transcription and administration of medication.

Med-Low

Sort #

What is being discussed? (Design Consideration)

Your Risk Estimate Your Priority

Project Data

Risk Data: Medication Safety

A Safety Risk Assessment for Healthcare Facility Environments

Why should this be considered? (Rationale) (This cell hyperlinks to references) Research shows that use of the bar-code eMAR substantially reduced the rate of errors in order transcription and in medication administration, as well as potential adverse drug events. Point of care bar code verification, and an integrated electronic medication record, can decrease or avert medication errors. The physical environment can enable this verification process at the point of care such as the patient bed, gurney or exam table. Consideration should also be provided to wiring buildings to accommodate new technology such as point of care bar code verification. In addition to understanding all the work tasks that will be performed in the space, it is important for the designer to have a sense of all the equipment and safety technology (linked to the work tasks). For example, mobile medication carts may be used to prepare and dispense medications. Interruptions and distractions to workers while using such carts can be minimized by providing access to a medication preparation room, or by providing designated spaces for these mobile carts within workspaces. Ready access to relevant information (lab results, drug info, vital signs and pertinent patient information) is a critical component of staff efficiency. The workspace organization has to address the information technology component relevant to the tasks performed in a particular medication safety zone.

V1.2 October2015

Location Key: GEN = General Consideration; OL = Overall Layout; IP = Inpatient; D&T = Diagnostic & Treatment; Rx = Pharmacy; ED = Emergency Department; HIM = Med. Records/Health Information Mgmt; OR = Operating; SEC = Seclusion

Sort #

Glossary/Definitions

The Risk Component Links

What is being discussed? (Design Consideration)

How is this done? Explanations/Clarifications (How Accomplished, Reasons Against)

B = Body (required); A = Appendix (suggested); N/I or blank = not included

Location

Risk Data: Medication Safety

A Safety Risk Assessment for Healthcare Facility Environments

FGI

52

200-Medication Safety Design

Building category

222 Design spaces to enable point of care barcode verification to reduce errors in the transcription and administration of medication. GEN

Technology Integration

223 Identify and provide the space needed for medication associated equipment (e.g., barcode reader, mobile medication cart, etc.) and safety technology (e.g., CPOE) in inpatient and outpatient medication safety zones. (This consideration is also relevant under the following category: room layout.)

GEN

Technology Integration

A

224 Enable ready access to clinical information, both patient specific and medication related, through the organization of the medication safety zone (MSZ) workspace.

GEN

Technology Integration

A

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Falls Risk Data

Home

Design Considerations:Falls

A Safety Risk Assessment for Healthcare Facility Environments

Safe Design Roadmap

Project Data

The Risk Component Links

Glossary/Definitions

Injury levels are often assessed as part of risk. As an example, the National Database of Nursing Quality Indicators classifies injury levels: none – the patient

Studies also show a range of fall locations in patient units ranging from 52-85% in the patient room (37-50% getting to the toilet), 8-29% in the patient bathroom, while others occur in corridors (6-7.4%) or stairs, as well as from chairs (8-16%). Other areas that can impact all hospital users include foodservice areas, areas surrounding drinking fountains and soap dispensers and building entrances. Waiting areas, dressing room, and procedure tables have also been identified in diagnostic and treatment areas.

The degree of potential harm related to falls may vary across a- risk populations and other factors. Studies include multi-factorial solutions that often include an increasing number of components whether the risk is low, medium or high. A panel of experts created a generic level of risk, but this should be considered with respect to your own organization and patient demographic. You might consider a typical “heat map” of risk throughout your decision process. A sample is shown.

Consequence

Certain patient groups might be more “at risk” for falls. Information may be found through: Joint Commission; CMS - Falls as HAC National Guideline Clearinghouse; PA Patient Safety Authority; University of Texas Health Science Center; Department of Veterans Affairs National Center for Patient Safety (VA NCPS); Foundation of Nursing Studies; CDC's National Institute for Occupational Safety and Health (NIOSH); and AHRQ.

Likelihood Rare

Unlikely

as a result of injuries sustained from the fall (not from physiologic events causing the fall). Is the likelihood rare or almost certain? Is the consequence negligible or minor injury or a sentinel event?

Possible

Sentinel event Partial Disability Medical Treatment First aid No injury or disability

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Likely

Almost Certain

54

Falls Risk Data

Home

Design Considerations:Falls

Safe Design Roadmap

Project Data

Evaluate historical data to ascertain all conditions (e.g., location, service type, patient populations) that contribute to falls in both inpatient and outpatient areas.

Location/Unit Type

Fall Rate/1,000 Patient Days

Copyright 2012-2015 The Center for Health Design. All Rights Reserved.

A Safety Risk Assessment for Healthcare Facility Environments The Risk Component Links

Glossary/Definitions

Past performance does not guarantee future results, but this may help identify the likelihood of events, specific to the organization. Are there patterns of vulnerability? Subject Matter Expert Consulted (Name)

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Title/Role

Data Source

55

300-Falls Design

301 Design unit layout to maximize ability for staff to easily see the patient's head in all rooms from work stations or a routine circulation pattern (e.g., no hidden rooms in the corners).

302 If direct visibility is not possible through unit layout, consider availability of additional patient monitoring (e.g., video surveillance, alarms). Also see 306. (This consideration is also relevant under the following category: technology integration.)

Copyright 2012-2015 The Center for Health Design. All Rights Reserved.

Safe Design Roadmap

Cost Magnitude

Your Priority

Generic Risk Estimate Med-Low Med-Low

300 Protect entrances from weather (e.g., canopies, walkoff mats).

Med-Low

Sort #

What is being discussed? (Design Consideration)

Your Risk Estimate

Project Data

Risk Data: Falls

A Safety Risk Assessment for Healthcare Facility Environments

Why should this be considered? (Rationale) (This cell hyperlinks to references) Canopies can protect entrances from inclement weather, while walk-off mats wide enough to cover the door width and long enough to capture several steps can reduce the tracking of contamination into the building (The Joint Commission, 2012). Umbrella bags can provide temporary measures (The Joint Commission, 2012), but should not become obstructions in the path of travel. Studies suggest locating higher risk patients closest to the nurse/team station. While this may be seen as operational, the design can support improved visibility and proximity through: 1) The unit shape to provide better sight lines (Amato, Salter, & Mion, 2006; Choi, Noblis, & Georgia Tech, 2011; Vassallo, Azeem, Pirwani, Sharma, & Allen, 2000); 2) The location of common tasks (e.g., charting) (Choi et al., 2011; Gutierrez & Smith, 2008.) 3) visibility of the patient head, including from the corridors with a normal walking pattern (Choi et al., 2011). While layouts should be designed to afford visibility, some interventions included assignments to specially equipped rooms (i.e., video surveillance) (Hardin, Dienemann, Rudisill, & Mills, 2013; Hitcho et al., 2004), but many studies include placement near the nurses’ station (Galbraith, Butler, Memon, Dolan, & Harty, 2011; Gutierrez & Smith, 2008; Hathaway, Walsh, Lacey, & Saenger, 2001; Hitcho et al., 2004; Kilpack, Boehm, Smith, & Mudge, 1991; Krauss et al., 2008; Quigley et al., 2009) or monitoring using bed alarms (Barker, Kamar, Morton, & Berlowitz, 2009; Carroll, Pappola, & McNicoll, 2009; GurascioHoward & Malloch, 2007; Kolin, Minnier, Hale, Martin, & Thompson, 2010; Krauss et al., 2008; McKinley et al., 2007; Morton, 1989; Spetz, Jacobs, & Hatler, 2007) .

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The Risk Component Links

How is this done? Explanations/Clarifications (How Accomplished, Reasons Against)

300 Protect entrances from weather (e.g., canopies, walkoff mats).

FGI

Building category

What is being discussed? (Design Consideration)

Location

Sort #

Location Key: GEN = General Consideration; OL = Overall Layout; IP = Inpatient; D&T = Diagnostic & B = Body (required); Treatment; Rx = Pharmacy; ED = Emergency Department; HIM = Med. Records/Health Information A = Appendix (suggested); Mgmt; OR = Operating; SEC = Seclusion N/I or blank = not included

Building GEN Envelope/Structu re

A

IP

Unit Layout

A

IP

Unit Layout

A

301 Design unit layout to maximize ability for staff to easily see the patient's head in all rooms from work stations or a routine circulation pattern (e.g., no hidden rooms in the corners).

302 If direct visibility is not possible through unit layout, consider availability of additional patient monitoring (e.g., video surveillance, alarms). Also see 306. (This consideration is also relevant under the following category: technology integration.)

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303 Provide space for families to be present in the patient room (e.g., encourage communication about falls, increase the level of patient surveillance).

305 Design location of call button/systems to be accessible and usable by the patient. (This consideration is also relevant under the following category: technology integration.)

Highest

Med-High

304 Provide room layout with clear and unobstructed paths of travel (e.g., storage, dedicated locations for commonly used moveable items).

Copyright 2012-2015 The Center for Health Design. All Rights Reserved.

Safe Design Roadmap

Cost Magnitude

Your Priority

Generic Risk Estimate Med-High

Sort #

What is being discussed? (Design Consideration)

Your Risk Estimate

Project Data

Risk Data: Falls

A Safety Risk Assessment for Healthcare Facility Environments

Why should this be considered? (Rationale) (This cell hyperlinks to references) Many organizations encourage use of family/sitters to stay with high-risk or confused patients to increase surveillance (Fonda, Cook, Sandler, & Bailey, 2006; Kilpack et al., 1991; Krauss et al., 2008; McCarter-Bayer, Bayer, & Hall, 2005) and sometimes assist patients with ambulation (Tzeng and Yin 2008). In one study, there were nearly half the falls in patient rooms that had designated family space as compared to those without (Calkins, Biddle, & Biesan, 2012) . Clutter may appear to be an operational issue but is influenced by the room and unit layout. A layout designed without space for necessary furniture, equipment and related cords may inherently create obstacles for staff and patients and many studies cite clutter as a condition of falls or removal as an intervention to reduce fall risk (Anonymous, 2011; Bell, Collins, Dalsey, & Sublet, 2010; Carroll et al., 2009; Gutierrez & Smith, 2008; Healey, 1994; Hitcho et al., 2004; Kilpack et al., 1991; Kolin et al., 2010; McKinley et al., 2007; Neiman, Rannie, Thrasher, Terry, & Kahn, 2011; Ruckstuhl, Marchionda, Salmons, & Larrabee, 1991; Szumlas, Groszek, Kitt, Payson, & Stack, 2004; Tzeng & Yin, 2008b). Inadequate storage facilities, either within the room or unit, can lead to unused equipment being left out, potentially in the paths of travel. Research papers often cite the call button within reach of the patient as an intervention to reduce falls (Hunderfund, Sweeney, Mandrekar, Johnson, & Britton, 2011; Kilpack et al., 1991; Lockwood & Anderson, 2013; Ruckstuhl et al., 1991; Schwendimann, 1998; Szumlas et al., 2004), although specific locations (e.g., bed. chair, toilet room) are not referenced . Consideration should be made for how the patient might reach the call device – a device located on the wall behind the toilet will be out of reach of many patients/residents. Patients may also fall while trying to reach a device.

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The Risk Component Links

How is this done? Explanations/Clarifications (How Accomplished, Reasons Against)

303 Provide space for families to be present in the patient room (e.g., encourage communication about falls, increase the level of patient surveillance).

IP

FGI

Building category

What is being discussed? (Design Consideration)

Location

Sort #

Location Key: GEN = General Consideration; OL = Overall Layout; IP = Inpatient; D&T = Diagnostic & B = Body (required); Treatment; Rx = Pharmacy; ED = Emergency Department; HIM = Med. Records/Health Information A = Appendix (suggested); Mgmt; OR = Operating; SEC = Seclusion N/I or blank = not included

Room Layout

A

GEN Room Layout

A

304 Provide room layout with clear and unobstructed paths of travel (e.g., storage, dedicated locations for commonly used moveable items).

305 Design location of call button/systems to be accessible and usable by the patient. (This consideration is also relevant under the following category: technology integration.)

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IP

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Room Layout

B

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300-Falls Design

Cost Magnitude

Your Priority

Generic Risk Estimate

One study found that bathroom locations visible from the bed, with the door open and out of the way, resulted in fewer falls, while a review referenced angled door and room layouts to provide better sight lines (Gulwadi & Calkins, 2008). It is possible that confused patients were better able to find and navigate to the bathroom when they did not have to manage opening a door (Calkins et al., 2012). Research concerning the location of the bathroom on the headwall versus the footwall is limited and inconclusive, although a recent study found lower fall rates when the bathroom was on the footwall (Calkins et al., 2012). Needs should be considered based on patient frailty and confusion (Hignett, Sands, & Griffiths, 2011, 2013) including the ease of the patient path to the bathroom (associated with frailty), the visibility for the patient (associated with confusion), and the visibility for staff (to see when a patient is trying to walk to the bathroom) (Amato et al., 2006; Choi et al., 2011; A. L. Hendrich, Fay, & Sorrells, 2004; Vassallo et al., 2000).

Highest

Highest

307 Locate bathroom in close proximity to the bed.

308 Provide space on the opening side (door handle side) of the patient toilet room door to facilitate the use of equipment and/or assistive devices. (See also patient handling items 410/411.) 309 Allow for smooth transitions in walking surfaces or between flooring types to avoid surface irregularities leading to trips. (See also patient handling item 418.)

Why should this be considered? (Rationale) (This cell hyperlinks to references)

Med-High

306 Design room layout so bathroom door is clearly identifiable from the bed. Also see 302.

Safe Design Roadmap

Med-High

Sort #

What is being discussed? (Design Consideration)

Your Risk Estimate

Project Data

Risk Data: Falls

A Safety Risk Assessment for Healthcare Facility Environments

Copyright 2012-2015 The Center for Health Design. All Rights Reserved.

A recent study found that rooms with 18” of space on the opening side of the door had a lower rate of falls (Calkins et al., 2012). It may be this made it possible to open the door without stepping backward and allowing patients the room to maneuver IV poles, walkers and other assistive devices. Changes in floor surfaces (e.g., soft surface to hard surface and/or slip resistance) (Anonymous, 2011; Yang & Hu, 2009) and unevenness (e.g., minor changes in height requiring transition strips, holes/cracks needing repair) can be a contributing factor for falls (Anonymous, 2003; Bell et al., 2010).

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The Risk Component Links

How is this done? Explanations/Clarifications (How Accomplished, Reasons Against)

FGI

Building category

What is being discussed? (Design Consideration)

Location

Sort #

Location Key: GEN = General Consideration; OL = Overall Layout; IP = Inpatient; D&T = Diagnostic & B = Body (required); Treatment; Rx = Pharmacy; ED = Emergency Department; HIM = Med. Records/Health Information A = Appendix (suggested); Mgmt; OR = Operating; SEC = Seclusion N/I or blank = not included

306 Design room layout so bathroom door is clearly identifiable from the bed. Also see 302. IP

Room Layout

A

IP

Room Layout

A

GEN Room Layout

A

307 Locate bathroom in close proximity to the bed.

308 Provide space on the opening side (door handle side) of the patient toilet room door to facilitate the use of equipment and/or assistive devices. (See also patient handling items 410/411.) 309 Allow for smooth transitions in walking surfaces or between flooring types to avoid surface irregularities leading to trips. (See also patient handling item 418.)

Copyright 2012-2015 The Center for Health Design. All Rights Reserved.

GEN

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Interior Design/Finishes

B

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313 Select slip-resistant flooring in potential wet areas (e.g., bathrooms, entrances, kitchens) and on ramps and stairs.

Med-High

312 Use floor materials and patterning to accurately convey the actual floor conditions (e.g., the perception of a level floor vs. a step or stair).

Highest

311 Design contrast to differentiate between the floors and walls.

Med-Low

Med-High

310 Design to minimize glare on floor (e.g., flooring material, lighting, windows).

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Safe Design Roadmap

Cost Magnitude

Your Priority

Generic Risk Estimate

Sort #

What is being discussed? (Design Consideration)

Your Risk Estimate

Project Data

Risk Data: Falls

A Safety Risk Assessment for Healthcare Facility Environments

Why should this be considered? (Rationale) (This cell hyperlinks to references) Shiny floors may contribute to falls by creating confusion about whether the floor is slippery (Joh, Adolph, Campbell, & Eppler, 2006). One study found that a shiny floor was always perceived as unsafe (Zamora, Alcantara, Artacho, & Cloquell, 2008) and another suggests cleaning practices that reduce high shine finishes (Fonda et al., 2006). When a surface is perceived as slippery, patients may change their step length, walking speed or the surface contact (Llewellyn & Nevola, 1992), with the elderly having lower abilities to adapt. This may contribute to decreased mobility (due to fear of falling) resulting in decrease leg strength, further contributing to falls. Reduced contrast sensitivity is indicated as a risk for falls (Harwood & Ebrahim, 1992). One suggested intervention includes contrast between floors and walls to better define the walking surface (including between the toilet and the surrounding floor and wall area) (Gulwadi & Calkins, 2008). Elderly are more reliant on vision for stabilization and poor visual acuity can double the risk of falls with contrast sensitivity also playing a role (Harwood & Ebrahim, 1992). A study related to carpet patterns and the elderly found that patterns featuring large areas of dark value next to areas of light value might be misinterpreted as shadows, changes in height, or objects on the floor (Perritt, McCune, & McCune, 2005). Additionally, light can create shadows that may be incorrectly perceived as a level change (Gulwadi & Calkins, 2008). Flooring selection should consider more than the coefficient of friction over the floor lifecycle, recognizing that multiple factors contribute to the slip resistance of a floor. Previously accepted ASTM testing methods (ASTM C1028-07e1) to determine the Static Coefficient of Friction of Ceramic Tile and Other Like Surfaces have been withdrawn (http://www.astm.org/Standards/C1028.htm) and it is important to understand the testing method used to determine slip resistance.

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A Safety Risk Assessment for Healthcare Facility Environments Glossary/Definitions

The Risk Component Links

How is this done? Explanations/Clarifications (How Accomplished, Reasons Against)

FGI

Building category

What is being discussed? (Design Consideration)

Location

Sort #

Location Key: GEN = General Consideration; OL = Overall Layout; IP = Inpatient; D&T = Diagnostic & B = Body (required); Treatment; Rx = Pharmacy; ED = Emergency Department; HIM = Med. Records/Health Information A = Appendix (suggested); Mgmt; OR = Operating; SEC = Seclusion N/I or blank = not included

310 Design to minimize glare on floor (e.g., flooring material, lighting, windows).

311 Design contrast to differentiate between the floors and walls.

GEN

Interior Design/Finishes

A

GEN

Interior Design/Finishes

A

GEN

Interior Design/Finishes

A

GEN

Interior Design/Finishes

B

312 Use floor materials and patterning to accurately convey the actual floor conditions (e.g., the perception of a level floor vs. a step or stair).

313 Select slip-resistant flooring in potential wet areas (e.g., bathrooms, entrances, kitchens) and on ramps and stairs.

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314 Select flooring and subflooring materials to mitigate injury in the event of a fall.

Highest

315 Secure walk-off mats, rugs and carpeting to the floor (e.g., entrances, lobbies, waiting areas).

Med-Low

316 Design lighting to eliminate abrupt changes in light levels.

Highest

317 Provide low-level lighting in nighttime/dark conditions.

Copyright 2012-2015 The Center for Health Design. All Rights Reserved.

Safe Design Roadmap

Cost Magnitude

Your Priority

Generic Risk Estimate Med-Low

Sort #

What is being discussed? (Design Consideration)

Your Risk Estimate

Project Data

Risk Data: Falls

A Safety Risk Assessment for Healthcare Facility Environments

Why should this be considered? (Rationale) (This cell hyperlinks to references) Research shows that softer underlays (e.g., wood versus concrete) may contribute to a reduction in injuries associated with patient falls through energy absorption. Certain materials may contribute more or less to the risk of falls, as well. In one study, linoleum flooring in both bedrooms and bathrooms was associated with more falls than either vinyl composition tile (VCT) or vinyl (Calkins et al., 2012).

Floor coverings that can roll up, buckle, or create a trip hazard due to thickness have been indicated as a contributor to employee, visitor and patient falls. This includes loose or frayed carpets and/or rugs and temporarily placed mats or runners that are used during inclement weather or in service areas (e.g., cafeteria kitchens) (Bell et al., 2010). Permanently affixed methods, recessed into the floor, may offer more control of surface irregularities, although material transition is still a consideration. Improper lighting can be a hazard for both staff and patients when it hides obstructions or does not allow visualization of the floor and equipment (Anonymous, 2003). Poor lighting can also lead to confusion in some patients, leading to the risk of falls (Oliver, 2007). In areas where monitors are used (e.g., procedure rooms, ORs), the contrast between the dimmed area for the monitor and surrounding bright areas may make it difficult to adapt vision (Anonymous, 2011; Brogmus, Leone, Butler, & Hernandez, 2007). This may also be true between patient rooms and hallways at night. Given the prevalence of night-time falls and falls en route to toileting, most implemented strategies suggest ensuring some form of low-level night lighting to help the patient navigate to the patient bathroom at night (Chen, Chen, & Su, 2010; Healey, 1994; Kilpack et al., 1991; Morse, 1998; Morton, 1989; Tzeng & Yin, 2008b). Night time lighting is intended to illuminate the path between the room entry/bed and the bed/toilet, but should not be so bright as to disrupt sleep.

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A Safety Risk Assessment for Healthcare Facility Environments Glossary/Definitions

The Risk Component Links

How is this done? Explanations/Clarifications (How Accomplished, Reasons Against)

FGI

Building category

What is being discussed? (Design Consideration)

Location

Sort #

Location Key: GEN = General Consideration; OL = Overall Layout; IP = Inpatient; D&T = Diagnostic & B = Body (required); Treatment; Rx = Pharmacy; ED = Emergency Department; HIM = Med. Records/Health Information A = Appendix (suggested); Mgmt; OR = Operating; SEC = Seclusion N/I or blank = not included

314 Select flooring and subflooring materials to mitigate injury in the event of a fall. IP

Interior Design/Finishes

A

GEN

Interior Design/Finishes

B

OR

Lighting

A

IP

Lighting

B, A

315 Secure walk-off mats, rugs and carpeting to the floor (e.g., entrances, lobbies, waiting areas).

316 Design lighting to eliminate abrupt changes in light levels.

317 Provide low-level lighting in nighttime/dark conditions.

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320 Mount grab bars and hand rails in the bathroom to support people of different height.

321 Consider toileting accessibility (e.g., toilet height, bedside location). This also applies to room layout.

Cost Magnitude

Your Priority

Generic Risk Estimate Med-High

While research has not confirmed the benefit of handrails from the patient bed to bathroom, expert opinions support their use (Kolin et al., 2010; Lowery, Buri, & Ballard, 2000; Tzeng & Yin, 2010). They should support patient weight while ambulating and some suggest prompting visibility at night through the use of sensors and low-level lighting (Kolin et al., 2010).

Highest

319 Locate grab bars on either side of the toilet to support patients getting up and down while toileting. Also see 318.

Why should this be considered? (Rationale) (This cell hyperlinks to references)

Research indicates that grab bars on both sides of the toilet helps the patient with the required push up force, in lieu of trying to use the sink (Fink, Pak, & Battisto, 2010). One study found that there were almost four times more falls with wall-mounted grab bars as compared to grab bars on both sides of the toilet (Calkins et al., 2012).

Highest

318 Locate grab bars and hand rails to support patients while ambulating to the toilet. Also see 319.

Safe Design Roadmap

Handrails in the bathroom and shower are often at awkward heights that require excessive bending and/or reaching. Some experts propose that the addition of grab bars at a secondary height is useful to address a varied population (Tzeng & Yin, 2010).

Med-High

Sort #

What is being discussed? (Design Consideration)

Your Risk Estimate

Project Data

Risk Data: Falls

A Safety Risk Assessment for Healthcare Facility Environments

Several studies reference low toilet height as a risk for falls (Fink et al., 2010; Lowery et al., 2000). Temporary solutions may include raised toilet seats or bedside commodes with locking wheels (Kilpack et al., 1991; Krauss et al., 2008; Morton, 1989; Schwendimann, 1998; Tzeng, 2011).

Highest

322 Select beds to afford low height positions and braking.

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Numerous studies indicate that beds with adjustable heights that can be used in a low-low position (lowered to the floor) can reduce falls (Barker et al., 2009; Fonda et al., 2006; Hunderfund et al., 2011; Kolin et al., 2010; Krauss et al., 2008; McKinley et al., 2007; Morton, 1989; Neiman et al., 2011; Quigley et al., 2009; Ruckstuhl et al., 1991; Schwendimann, 1998; Szumlas et al., 2004; Tzeng & Yin, 2008b). Even in a low position, hospital bedframes are often 8-12” higher than a home bed (Tzeng & Yin, 2008a)

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The Risk Component Links

How is this done? Explanations/Clarifications (How Accomplished, Reasons Against)

FGI

Building category

What is being discussed? (Design Consideration)

Location

Sort #

Location Key: GEN = General Consideration; OL = Overall Layout; IP = Inpatient; D&T = Diagnostic & B = Body (required); Treatment; Rx = Pharmacy; ED = Emergency Department; HIM = Med. Records/Health Information A = Appendix (suggested); Mgmt; OR = Operating; SEC = Seclusion N/I or blank = not included

318 Locate grab bars and hand rails to support patients while ambulating to the toilet. Also see 319. IP

319 Locate grab bars on either side of the toilet to support patients getting up and down while toileting. Also see 318.

320 Mount grab bars and hand rails in the bathroom to support people of different height.

Equipment

A

GEN Equipment

A

GEN Equipment

N/I

IP

Plumbing

N/I

IP

Furnishings

321 Consider toileting accessibility (e.g., toilet height, bedside location). This also applies to room layout.

322 Select beds to afford low height positions and braking.

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A

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326 Consider fall risks from furniture/equipment where procedures are performed (e.g., radiology, surgery, ED).

327 Select call and communication systems designed to minimize public noise.

Med-Low Med-High

325 Consider ergonomic design in furniture selection to reduce staff fatigue (e.g., adjustable heights, standing workstations).

Highest

324 Select/specify furniture to support independent mobility of patients.

Lowest

Lowest

323 Minimize unnecessary restraints in furniture selection (including the use of bilateral full-length bed rails).

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Safe Design Roadmap

Cost Magnitude

Your Priority

Generic Risk Estimate

Sort #

What is being discussed? (Design Consideration)

Your Risk Estimate

Project Data

Risk Data: Falls

A Safety Risk Assessment for Healthcare Facility Environments

Why should this be considered? (Rationale) (This cell hyperlinks to references) Studies find the use of bedrails and restraints do not contribute to a reduced rate of falls (Capezuti, Maislin, Strumpf, & Evans, 2002) and may contribute to an increased risk of falls (Ash, MacLeod, & Clark, 1998; Capezuti, Strumpf, Evans, Grisso, & Maislin, 1998; Hanger, Ball, & Wood, 1999; van Leeuwen, Bennett, West, Wiles, & Grasso, 2001), although even some recent studies indicate this intervention is in place as part of a multi-factorial falls reduction program (Lockwood & Anderson, 2013; Neiman et al., 2011). In contrast to supporting mobility, chair lap trays have been cited as a risk factor, and can be defined as restraints despite their intended purpose . For example, they may be attached to chairs to prevent people getting up without assistance (Tan et al., 2005). Unstable furniture has been cited as a risk factor for falls (Gulwadi & Calkins, 2008). Slips, trips, and falls can be exacerbated by fatigue. A best practice paper on OR design suggests ergonomically adjustable furniture and equipment, as well as standing workstations with padded leaning rests (Brogmus et al., 2007). This may apply to other areas, as well. A report on the risk of falls in Radiology areas found that falls were associated with the instability of procedure tables when patients were entering or exiting (Anonymous, 2011). Another study used portable padded siderails during pediatric surgery to reduce the risk of patient falls from the table during surgery (Redman & Mcnatt, 2000). Noisy environments can lead to confusion in older hospitalized patients, sometimes leading to restlessness and the risk of falls (Oliver, 2007). One study found that when both overhead paging and alarms were rated as occurring “frequently,” falls were statistically higher (Calkins et al., 2012).

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The Risk Component Links

How is this done? Explanations/Clarifications (How Accomplished, Reasons Against)

FGI

Building category

What is being discussed? (Design Consideration)

Location

Sort #

Location Key: GEN = General Consideration; OL = Overall Layout; IP = Inpatient; D&T = Diagnostic & B = Body (required); Treatment; Rx = Pharmacy; ED = Emergency Department; HIM = Med. Records/Health Information A = Appendix (suggested); Mgmt; OR = Operating; SEC = Seclusion N/I or blank = not included

323 Minimize unnecessary restraints in furniture selection (including the use of bilateral full-length bed rails). IP

Furnishings

A

IP

Furnishings

A

GEN Furnishings

A

D&T Furnishings

A

Technology Integration

A

324 Select/specify furniture to support independent mobility of patients.

325 Consider ergonomic design in furniture selection to reduce staff fatigue (e.g., adjustable heights, standing workstations). 326 Consider fall risks from furniture/equipment where procedures are performed (e.g., radiology, surgery, ED).

327 Select call and communication systems designed to minimize public noise.

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IP

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328 Control noise through the design (e.g., material selection).

Med-Low

329 Allow space for safety alert signage (e.g., fall risk, isolation precaution) at the patient room entrance and/or the patient bed.

Copyright 2012-2015 The Center for Health Design. All Rights Reserved.

Safe Design Roadmap

Cost Magnitude

Your Priority

Generic Risk Estimate Med-High

Sort #

What is being discussed? (Design Consideration)

Your Risk Estimate

Project Data

Risk Data: Falls

A Safety Risk Assessment for Healthcare Facility Environments

Why should this be considered? (Rationale) (This cell hyperlinks to references) Sleep disturbances are common in older people and are associated with their risk of falling (Hill et al., 2009), and noise reduction can improve sleep. Noise is often generated by conversations, foot traffic, movement of carts and equipment and can be migrated with material selection. High performance ceiling tile, flooring, and acoustical wall coverings can aid in reducing both sound levels and reverberation. Numerous studies reference visual cues so that staff and visitors are alerted to a fall risk condition (e.g., signage, colored wrist bands, blanket color, footwear). This includes visible signage at the door and sometimes at the patient headwall (Ang, Mordiffi, & Wong, 2011; Barker et al., 2009; Carroll et al., 2009; Dykes & Carroll, 2010; Hunderfund et al., 2011; Kilpack et al., 1991; Krauss et al., 2008; Morton, 1989; Neiman et al., 2011; Schwendimann, 1998). Because signage is mostly considered later in the design process, suitable wall space at the room entry is often lacking.

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The Risk Component Links

How is this done? Explanations/Clarifications (How Accomplished, Reasons Against)

FGI

Building category

What is being discussed? (Design Consideration)

Location

Sort #

Location Key: GEN = General Consideration; OL = Overall Layout; IP = Inpatient; D&T = Diagnostic & B = Body (required); Treatment; Rx = Pharmacy; ED = Emergency Department; HIM = Med. Records/Health Information A = Appendix (suggested); Mgmt; OR = Operating; SEC = Seclusion N/I or blank = not included

328 Control noise through the design (e.g., material selection). IP

Interior Design/Finishes

A

IP

Interior Design/Finishes

N/I

329 Allow space for safety alert signage (e.g., fall risk, isolation precaution) at the patient room entrance and/or the patient bed.

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PH Risk Data

Home

Design Considerations: Patient Handling

A Safety Risk Assessment for Healthcare Facility Environments

Safe Design Roadmap

Project Data

The Risk Component Links

Glossary/Definitions

Harm resulting from unsafe patient handling includes staff injuries and musculoskeletal disorders, patient fall-related injuries, patient pressure ulcers, medical expenses, disability compensation, time lost from work and turnovers. The specific types of probable adverse events and the degree of potential harm (e.g., patient falls, patient ulcer pressures and staff back injuries resulted from patient handling) should be identified based upon the at-risk populations identified. Is the likelihood rare or almost certain? Is the consequence negligible or minor injury or a sentinel event?

A healthcare organization should evaluate historical data (e.g., patient and staff injury data) as well as emerging risks (e.g., bariatric) to identify patient and staff populations most at risk for adverse outcomes related to patient handling and movement in all patient care areas. Evaluate historical data to ascertain all conditions that contribute to risks involved with patient handling and movement.

A panel of experts created a generic level of risk, but this should be considered with respect to your own organization and patient demographic. You might consider a typical “heat map” of risk throughout your decision process. A sample is shown.

Consequence

Patient handling and movement (PHAM) refers to a set of important patient care activities (i.e. transferring positioning/repositioning, transportation of patients) that impact not only patient safety (e.g., pressure ulcers) and care quality (e.g., depression) but also staff safety (e.g., staff back injuries). Certain patient groups (e.g., bariatric) might pose more “risks” for safety issues related to patient handling and movement. Relatively higher risks of injury have been identified for some patient care areas including patient bathrooms, extended care units, and diagnostic units. The degree of potential harm related to patient handling and movementvaries across at-risk populations.

Likelihood Rare

Unlikely

Possible

Sentinel event Partial disability Medical treatment First aid No injury or disability

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Likely

Almost Certain

72

PH Risk Data

Home

Design Considerations: Patient Handling

Safe Design Roadmap

Project Data

Evaluate historical data to ascertain all conditions (e.g., service type, patient populations) that contribute to harm in both inpatient and outpatient areas.

Location/Unit Type

Harm or staff injury rate

Copyright 2012-2015 The Center for Health Design. All Rights Reserved.

A Safety Risk Assessment for Healthcare Facility Environments

The Risk Component Links

Glossary/Definitions

Past performance does not guarantee future results, but this may help identify the likelihood of events specific to the organization. Are there patterns of vulnerability?

Subject Matter Expert Consulted (Name)

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Title/Role

Data Source

73

400-Patient Handling Design

402 Provide patient elevators to accommodate patient beds/stretchers for the transportation of special patients such as bariatric patients.

403 Minimize the time, physical effort and risks associated with transporting patients between departments and units through building design (e.g., ample corridor width, minimal turns, wide doorways without thresholds, open layout, elevators with ample spaces to accommodate bariatric beds, etc.).

Cost Magnitude

Your Priority

Generic Risk Estimate Med-Low

Why should this be considered? (Rationale) (This cell hyperlinks to references) Patient transport or movement between hospital departments and units are frequently associated with complications causing harmful effects on patients. Research has found that longer transport duration cause more frequent and serious complications and harms (Ulrich & Zhu, 2007). Physical proximity of destination points on frequent patient transport routes may help facilitate the patient movement and reduce transport duration, therefore improve safety by reducing risk of patient complications and staff injuries during transportation, and improve efficiency by reducing staff time spent on patient transport.

Highest

401 Locate departments and units that patients are frequently transported from/to as close to each other as possible (e.g., ED and imaging if ED imaging is a most frequent patient transport route).

Safe Design Roadmap

The trend of more bariatric patients being seen in hospitals presents a challenge to healthcare. The availability of elevators has been found to significantly impact the movement of patients, especially bariatric patients. It is important to consider the weight and size limits of patient elevators so that special patients and equipment can be accommodated (Muir & Archer-Heese, 2009).

Highest

Sort #

What is being discussed? (Design Consideration)

Your Risk Estimate

Project Data

Risk Data: Patient Handling

A Safety Risk Assessment for Healthcare Facility Environments

Patient transport or movement between hospital departments and units are frequently associated with complications causing harmful effects on patients. Longer transport duration was found in research to cause more frequent and serious complications and harms (Ulrich & Zhu, 2007). Beside the physical proximity (see #401), certain building elements (e.g., design of corridors, ramps, doorways) may facilitate or hinder patient movement between units and department within a hospital thus impact the time, physical effort, and risks associated with transporting patients.

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400-Patient Handling Design Risk Data: Patient Handling

A Safety Risk Assessment for Healthcare Facility Environments Glossary/Definitions

The Risk Component Links

What is being discussed? (Design Consideration)

How is this done? Explanations/Clarifications (How Accomplished, Reasons Against)

401 Locate departments and units that patients are frequently transported from/to as close to each other as possible (e.g., ED and imaging if ED imaging is a most frequent patient transport route).

402 Provide patient elevators to accommodate patient beds/stretchers for the transportation of special patients such as bariatric patients.

403 Minimize the time, physical effort and risks associated with transporting patients between departments and units through building design (e.g., ample corridor width, minimal turns, wide doorways without thresholds, open layout, elevators with ample spaces to accommodate bariatric beds, etc.).

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FGI

Location

Sort #

Location Key: GEN = General Consideration; OL = Overall Layout; IP = Inpatient; D&T = Diagnostic & B = Body (required); Treatment; Rx = Pharmacy; ED = Emergency Department; HIM = Med. Records/Health Information A = Appendix (suggested); Mgmt; OR = Operating; SEC = Seclusion N/I or blank = not included

Building category

GEN

Building Layout

A

GEN

Building Layout

B

GEN

Building Layout

B,A

75

400-Patient Handling Design

405 Select patient handling assistive devices at specific units or areas according to the following considerations and criteria: -patient dependency -patient weight and size -projected patient populations -patient handling tasks -transfer time -risk of injury -ease of use -space/structural/other requirements 406 Provide adequate clearance in both width and ceiling height in unit corridors and patient rooms to accommodate use of patient handling and movement assistive equipment. (This consideration is also relevant under the following category: unit layout.)

Copyright 2012-2015 The Center for Health Design. All Rights Reserved.

Safe Design Roadmap

Cost Magnitude

Your Priority

Generic Risk Estimate Med-High Highest

404 Consider flexibility and adaptability of patient room design (e.g., bariatric patient room, universal room, spaces for portable CT scanners) in order to reduce the needs of patient transport.

Med-High

Sort #

What is being discussed? (Design Consideration)

Your Risk Estimate

Project Data

Risk Data: Patient Handling

A Safety Risk Assessment for Healthcare Facility Environments

Why should this be considered? (Rationale) (This cell hyperlinks to references) Patient transport or movement between hospital departments and units are frequently associated with complications causing harmful effects on patients (Ulrich & Zhu, 2007). Research shows that certain room designs that are more flexible and adaptable (e.g., acuity-adaptable rooms, bariatric patient room, universal room, spaces for portable CT scanners) can reduce the needs of patient transport and movement within a hospital therefore reduce the risk of complications associated with patient transport (A. Hendrich, Fay, & Sorrells, 2004). Various patient handling and movement devices have pros and cons, and are suitable under different conditions (e.g., different patient handling tasks for different patient groups) (Alamgir et al., 2009; Nelson et al., 2004). The selection of patient handling and movement devices should be based on considerations on multiple influencing factors that are listed.

Spatial requirements for using patient handling and movement equipment vary significantly (Hignett & Evans, 2006). Unit corridor width and height should accommodate the use of patient handling or movement assistive devices. For example, ambulating a tall patient (>5'6") on a ceiling lift is nearly impossible in a corridor with a 8 foot ceiling. In addition, there should be enough clearance between the placement of a lift and the edge of the corridor to allow a person of wider girth to ambulate freely.

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400-Patient Handling Design Risk Data: Patient Handling

A Safety Risk Assessment for Healthcare Facility Environments Glossary/Definitions

The Risk Component Links

What is being discussed? (Design Consideration)

How is this done? Explanations/Clarifications (How Accomplished, Reasons Against)

404 Consider flexibility and adaptability of patient room design (e.g., bariatric patient room, universal room, spaces for portable CT scanners) in order to reduce the needs of patient transport.

405 Select patient handling assistive devices at specific units or areas according to the following considerations and criteria: -patient dependency -patient weight and size -projected patient populations -patient handling tasks -transfer time -risk of injury -ease of use -space/structural/other requirements 406 Provide adequate clearance in both width and ceiling height in unit corridors and patient rooms to accommodate use of patient handling and movement assistive equipment. (This consideration is also relevant under the following category: unit layout.)

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FGI

Location

Sort #

Location Key: GEN = General Consideration; OL = Overall Layout; IP = Inpatient; D&T = Diagnostic & B = Body (required); Treatment; Rx = Pharmacy; ED = Emergency Department; HIM = Med. Records/Health Information A = Appendix (suggested); Mgmt; OR = Operating; SEC = Seclusion N/I or blank = not included

Building category

GEN

Room Layout

GEN

Equipment

B,A

GEN

Room Layout

B,A

77

400-Patient Handling Design

409 Ensure the safe and easy movement and use of patient handling and mobility equipment (e.g., patient rooms as well as diagnostic / operating / holding area / rehabilitation rooms) when designing the room layout in all areas where patient care is provided. 410 Design the patient bathroom layout to facilitate safe and effective use of patient handling and movement equipment. (See also falls items 308.)

411 Make patient room and bathroom doors wide and tall enough for the use of patient handling and movement devices. (See also falls items 308.)

Cost Magnitude

Your Priority

Generic Risk Estimate Med-High Med-Low

Patient handling and movement assistive devices/equipment may take up precious patient care space. They should be stored away when not in use to avoid causing clutter that often result in other safety risks such as falls (see #304).

Electrical supply is necessary for charging and using many types of patient handling and movement equipment. Inconvenient, hard-to-reach locations of electrical outlets may impede the use of patient handling and movement equipment. Extra spaces may be needed for the safe and efficient maneuver/use of patient handling and movement equipment; the spatial requirements vary significantly across different pieces of equipment (Hignett & Evans, 2006). Various patient handling and movement devices’ spatial requirements should be considered in determining the layout of patient care spaces including patient rooms as well as other spaces where patient care activities occur. Staff members perform many patient handling tasks in bathrooms. Bathrooms typically have tight space and potentially could hinder the use of certain patient handling and movement equipment. Like ADA bathroom design, the use of the patient handling devices should be considered in patient bathroom layout design (Hignett & Evans, 2006). Often, staff needs to move patient through room doors when they use patient handling and movement equipment to support or assist patients (for example, moving a patient on bed/wheelchair/lift). The door clearances should be big enough to allow safe and efficient passage of patient, staff, together with the equipment.

Highest

408 Optimize locations of electrical supply for charging and/or using patient handling equipment so they are easily accessible for the users.

Why should this be considered? (Rationale) (This cell hyperlinks to references)

Highest

407 Designate enough conveniently located storage spaces for patient handling equipment and accessory supplies (e.g., slings, lateral transfer devices, slide boards) in each area where patient handling occurs, including rooms for patient care. (This consideration is also relevant under the following category: unit layout.)

Safe Design Roadmap

Highest

Sort #

What is being discussed? (Design Consideration)

Your Risk Estimate

Project Data

Risk Data: Patient Handling

A Safety Risk Assessment for Healthcare Facility Environments

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400-Patient Handling Design Risk Data: Patient Handling

A Safety Risk Assessment for Healthcare Facility Environments Glossary/Definitions

The Risk Component Links

What is being discussed? (Design Consideration)

How is this done? Explanations/Clarifications (How Accomplished, Reasons Against)

407 Designate enough conveniently located storage spaces for patient handling equipment and accessory supplies (e.g., slings, lateral transfer devices, slide boards) in each area where patient handling occurs, including rooms for patient care. (This consideration is also relevant under the following category: unit layout.)

FGI

Location

Sort #

Location Key: GEN = General Consideration; OL = Overall Layout; IP = Inpatient; D&T = Diagnostic & B = Body (required); Treatment; Rx = Pharmacy; ED = Emergency Department; HIM = Med. Records/Health Information A = Appendix (suggested); Mgmt; OR = Operating; SEC = Seclusion N/I or blank = not included

Building category

GEN

Room Layout

B,A

GEN

Mechanical (HVAC)/Electrical

A

GEN

Room Layout

B,A

410 Design the patient bathroom layout to facilitate safe and effective use of patient handling and movement equipment. (See also falls items 308.)

GEN

Room Layout

B,A

411 Make patient room and bathroom doors wide and tall enough for the use of patient handling and movement devices. (See also falls items 308.)

GEN

Room Layout

B,A

408 Optimize locations of electrical supply for charging and/or using patient handling equipment so they are easily accessible for the users. 409 Ensure the safe and easy movement and use of patient handling and mobility equipment (e.g., patient rooms as well as diagnostic / operating / holding area / rehabilitation rooms) when designing the room layout in all areas where patient care is provided.

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400-Patient Handling Design

415 Make structural design support the current and anticipated requirements for using ceiling- and/or wallmounted overhead patient lifts.

416 Make ceiling design (including ceiling track systems, ceiling height) support the use of ceiling lifts or walkway devices in the applicable rooms and units.

Copyright 2012-2015 The Center for Health Design. All Rights Reserved.

Safe Design Roadmap

Cost Magnitude

Your Priority

Generic Risk Estimate Med-Low MedLow Med-Low

414 Position lighting fixtures to accommodate the clinical needs as well as allow patient handling assistive devices/equipment such as ceiling lifts wherever possible/practical.

Med-High

412 Designate enough conveniently located storage spaces in each patient room for patient specific patient handling accessory supplies (e.g., slings, lateral transfer devices, slide boards). 413 Provide enough illumination in ambient and task lighting for patient handling and movement tasks.

Highest

Sort #

What is being discussed? (Design Consideration)

Your Risk Estimate

Project Data

Risk Data: Patient Handling

A Safety Risk Assessment for Healthcare Facility Environments

Why should this be considered? (Rationale) (This cell hyperlinks to references) Enough storage spaces for patient handling and movement devices that are designed to be stored in patient rooms may help reduce clutter.

Proper lighting level is needed to allow safe operating of patient handling and movement devices and prevent injuries or errors (for example, slips, falls) for both staff and patient during patient handling and movement. In certain circumstances, the positioning of lighting fixtures may need to meet the needs of clinical procedures as well as operating patient handling assistive devices/equipment. Conflicts between lighting fixtures and patient handling equipment could cause operational issues, for example, inconvenient ceiling lift track locations, non-optimal lighting angles, etc. The installation of certain patient handling and movement equipment may have special requirements in terms of structural loading on walls, ceilings, or floors. Insufficient structural support may make the use of patient handling and movement equipment unsafe or cause injuries during use. This becomes an even more important issue when the needs of bariatric patients are considered. Many types of patient handling and movement equipment, including ceiling lifts, are need adequate ceiling clearance to appropriately operate. These patient handling and movement devices’ specific requirements for ceiling design including ceiling track systems, ceiling height, and so on should be considered during design to avoid costly changes later.

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400-Patient Handling Design Risk Data: Patient Handling

A Safety Risk Assessment for Healthcare Facility Environments Glossary/Definitions

The Risk Component Links

What is being discussed? (Design Consideration)

How is this done? Explanations/Clarifications (How Accomplished, Reasons Against)

412 Designate enough conveniently located storage spaces in each patient room for patient specific patient handling accessory supplies (e.g., slings, lateral transfer devices, slide boards). 413 Provide enough illumination in ambient and task lighting for patient handling and movement tasks.

FGI Building category

B,A

414 Position lighting fixtures to accommodate the clinical needs as well as allow patient handling assistive devices/equipment such as ceiling lifts wherever possible/practical. 415 Make structural design support the current and anticipated requirements for using ceiling- and/or wallmounted overhead patient lifts.

GEN

Lighting

B

GEN

Lighting

A

Building GEN Envelope/Structu re

416 Make ceiling design (including ceiling track systems, ceiling height) support the use of ceiling lifts or walkway devices in the applicable rooms and units.

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Location

Sort #

Location Key: GEN = General Consideration; OL = Overall Layout; IP = Inpatient; D&T = Diagnostic & B = Body (required); Treatment; Rx = Pharmacy; ED = Emergency Department; HIM = Med. Records/Health Information A = Appendix (suggested); Mgmt; OR = Operating; SEC = Seclusion N/I or blank = not included

GEN

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Interior Design/Finishes

B

B,A

81

400-Patient Handling Design

418 Minimize thresholds, ramps or other potential barriers on flooring in patient care areas (or building entry ways) that may hinder safe and effective use of patient handling and movement equipment. (See also falls item 309.)

Copyright 2012-2015 The Center for Health Design. All Rights Reserved.

Safe Design Roadmap

Cost Magnitude

Your Priority

Generic Risk Estimate Highest

417 Specify flooring materials suitable for moving and maneuvering wheeled patient handling and movement devices in spaces where patient handling and movement tasks are performed.

Med-High

Sort #

What is being discussed? (Design Consideration)

Your Risk Estimate

Project Data

Risk Data: Patient Handling

A Safety Risk Assessment for Healthcare Facility Environments

Why should this be considered? (Rationale) (This cell hyperlinks to references) Like many other types of healthcare equipment, certain patient handling and movement equipment such as floor lifts, wheelchairs, and patient beds, are floor based and move on wheels. Flooring materials differ significantly in terms of rolling resistance. Inappropriate flooring material may require staff to exert excessive forces to move the wheeled equipment in certain situations (e.g., uphill, slippery floor), and increases level of risk of staff sustaining physical injuries. Thresholds, ramps and other obstacles on flooring may hinder the use of certain floorbased patient handling devices and increase the risk of injuries due to slips, bumps and falls. Physical barriers (or obstacles) may hinder the process of moving patients in or out of hospitals therefore cause delays or errors in patient care.

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400-Patient Handling Design Risk Data: Patient Handling

A Safety Risk Assessment for Healthcare Facility Environments Glossary/Definitions

The Risk Component Links

What is being discussed? (Design Consideration)

How is this done? Explanations/Clarifications (How Accomplished, Reasons Against)

417 Specify flooring materials suitable for moving and maneuvering wheeled patient handling and movement devices in spaces where patient handling and movement tasks are performed.

418 Minimize thresholds, ramps or other potential barriers on flooring in patient care areas (or building entry ways) that may hinder safe and effective use of patient handling and movement equipment. (See also falls item 309.)

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FGI

Location

Sort #

Location Key: GEN = General Consideration; OL = Overall Layout; IP = Inpatient; D&T = Diagnostic & B = Body (required); Treatment; Rx = Pharmacy; ED = Emergency Department; HIM = Med. Records/Health Information A = Appendix (suggested); Mgmt; OR = Operating; SEC = Seclusion N/I or blank = not included

Building category

GEN

Interior Design/Finishes

B,A

GEN

Interior Design/Finishes

B,A

83

Behavioral Health Risk Data

Home

Design Considerations: Behavioral Health

Safe Design Roadmap

Project Data

Certain locations or patient groups might be more “at risk.” For example, studies indicate that while the majority of self-harm and violence against others occurs in a behavioral health-specific unit, other departments of the facility are affected as well. This often includes the ED, but also affects other inpatient units. Clinicians indicate that medical conditions for behavioral health may result in agitation or manic energy being directed towards the environment and structure.

Consequence

Based upon the "at risk" considerations identified, and available data, the degree of potential harm must be identified (e.g., injury, sentinel event) to help establish priorities during the process. This may be supplemented by national data.

Likelihood Rare

A Safety Risk Assessment for Healthcare Facility Environments

Glossary/Definitions

Nationally available data specific to issues of behavioral health self-harm and workplace violence in healthcare settings is sparse. The Joint Commission reports data on sentinel event root cause analysis related to suicide in participating hospitals, and some states track overall suicide statistics that include hospital suicides. With respect to violence against healthcare workers, the Bureau of Labor Statistics collects data by industry, and NIOSH and OSHA provide guidance on prevention programs which includes background data. Is the likelihood rare or almost certain? Is the consequence negligible or minor injury or a sentinel event? A panel of experts created a generic level of risk, but this should be considered with respect to your own organization and patient demographic. You might consider a typical “heat map” of risk throughout your decision process. A sample is shown.

Unlikely

Possible

Sentinel event Partial disability Medical treatment First aid No injury or disability

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The Risk Component Links

V1.2 October2015

Likely

Almost Certain

84

Behavioral Health Risk Data

Home

Design Considerations: Behavioral Health

Safe Design Roadmap

Project Data

Evaluate historical data to ascertain all conditions (e.g., service type, patient populations) that contribute to self-harm in both inpatient and outpatient areas.

Location/Unit Type

Harm type/rate

Copyright 2012-2015 The Center for Health Design. All Rights Reserved.

A Safety Risk Assessment for Healthcare Facility Environments

The Risk Component Links

Glossary/Definitions

Past performance does not guarantee future results, but this may help identify the likelihood of events, specific to the organization. Are there patterns of vulnerability?

Subject Matter Expert

V1.2 October2015

Title/Role

Data Source

85

500-Behavioral Health Design

503 Select and design exterior landscaping to eliminate access to roofs, fences or walls that could lead to elopement. 504 Design exterior landscaping to allow visibility and surveillance by staff where patients have outdoor access. 505 Select non-toxic exterior and interior landscaping to preclude use as a weapon (e.g., branches). 506 Provide visual and/or physical access to nature for patients.

Copyright 2012-2015 The Center for Health Design. All Rights Reserved.

Safe Design Roadmap

Cost Magnitude

Generic Risk Estimate MedLow MedLow Lowest MedHigh

502 Secure outdoor perimeter in a manner appropriate for the population served.

Med-High

501 Include exterior fences and walls designed to mitigate elopement.

MedLow

500 Ensure exterior areas accessible to the unit or patients are well lit.

Med-Low

Sort #

What is being discussed? (Design Consideration)

Your Risk Estimate Your Priority

Project Data

Risk Data: Injury - Behavioral Health

A Safety Risk Assessment for Healthcare Facility Environments

Why should this be considered? (Rationale) (This cell hyperlinks to references) Experts cite the need for adequate exterior lighting with vandal-proof bulkhead fittings (C. Curran, 2005; J. Hunt & Sine, 2014). The design should also preclude light being directed into patient rooms (J. Hunt & Sine, 2014). Expert opinion suggests that outdoor areas should be securely walled with solid masonry walls or screened with mesh steel (suitable to the population) to a height to prevent overlooking and escape (C. Curran, 2005; J. Hunt & Sine, 2014). High fences that give an appearance that the unit contains dangerous individuals who must be quarantined from the general community are likely to impact negatively on patients’ sense of physical safety (Dobrohotoff & Llewellyn-Jones, 2011). The authors of the NAPHS guidelines for behavioral health cite the relationship between exterior landscaping (e.g., position of trees or shrubs), elopement and roof access (J. Hunt & Sine, 2014). According to the authors of the NAPHS guidelines for behavioral health, exterior landscaping that is planted too close together can create barriers to staff visualization of patients, as well as becoming places to hide (J. Hunt & Sine, 2014). Staff should have visual access to patients in outdoor spaces. Commonly used guidelines for behavioral health design cite the relationship between plants and their potential use as a weapon or as a poisoning agent (J. Hunt & Sine, 2014). The authors of a literature review cite sources that suggest that violence is associated with patient density (spatial and social), a lack of privacy and control, which may be reduced by providing direct access to usable outdoor space, also allowing for patient choice and control (Dobrohotoff & Llewellyn-Jones, 2011).

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500-Behavioral Health Design Risk Data: Injury - Behavioral Health

A Safety Risk Assessment for Healthcare Facility Environments Glossary/Definitions

The Risk Component Links

What is being discussed? (Design Consideration)

How is this done? Explanations/Clarifications (How Accomplished, Reasons Against)

FGI

Location

Sort #

Location Key: GEN = General Consideration; OL = Overall Layout; IP = Inpatient; D&T = Diagnostic & B = Body (required); Treatment; Rx = Pharmacy; ED = Emergency Department; HIM = Med. Records/Health Information A = Appendix (suggested); Mgmt; OR = Operating; SEC = Seclusion N/I or blank = not included

Building category

500 Ensure exterior areas accessible to the unit or patients are well lit.

GEN Site Optimization

N/I

501 Include exterior fences and walls designed to mitigate elopement.

GEN Site Optimization

B

GEN Site Optimization

N/I

GEN Site Optimization

B

GEN Site Optimization

N/I

GEN Site Optimization

B

GEN Site Optimization

N/I

502 Secure outdoor perimeter in a manner appropriate for the population served.

503 Select and design exterior landscaping to eliminate access to roofs, fences or walls that could lead to elopement. 504 Design exterior landscaping to allow visibility and surveillance by staff where patients have outdoor access. 505 Select non-toxic exterior and interior landscaping to preclude use as a weapon (e.g., branches). 506 Provide visual and/or physical access to nature for patients.

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500-Behavioral Health Design

510 Locate security in close proximity to behavioral health units to allow quick response times.

511 Secure or design to mitigate jumping in any areas where the risk of jumping may be an issue (e.g., roof, balcony, porch, window).

Cost Magnitude

Highest

Research indicates limited (e.g., sash control devices) or no operability of windows (e.g., fixed panes, special locking) reduces the risk of jumping. Heavy duty screens might also be considered for non- behavioral health areas where lower risk is anticipated (ECRI Institute & The Institute for Safe Medication Practices, 2007; Gournay & Bowers, 2000; J. Hunt & Sine, 2014; Lieberman, Resnik, & Holder-Perkins, 2004; New York State Office of Mental Health & architecture +, 2012).

Highest

Generic Risk Estimate Med-Low

While outdoor areas may offer therapeutic benefit, staff supervision needs to considered based on the patient population (Dobrohotoff & Llewellyn-Jones, 2011; J. Hunt & Sine, 2014) including natural surveillance - the placement of physical features, activities and people in such a way as to maximize visibility (McPhaul et al., 2008).

Glass shards can be used as a weapon for self-harm or harm against others. This applies to both exterior windows and lites in interior doors, such as seclusion rooms. Tempered glass, laminated glass, and polycarbonates all have different properties to be considered (e.g., large shards and/or ability to remain in the frame) (C. Curran, 2005; ECRI Institute & The Institute for Safe Medication Practices, 2007; Gournay & Bowers, 2000; J. Hunt & Sine, 2014; Lieberman et al., 2004). One paper referenced the increase in response time (more than doubled) associated with renovations and additions that added elevators and doors with badge access (Yeager et al., 2005). Adjacencies to high risk areas should always be considered. In several cases of suicide, patients were able to jump from a roof due to a door that was left unsecured or was not easily visible to the staff (Gournay & Bowers, 2000). According to other studies, additional areas beyond the roof need to be considered, such as atria, balconies, porches, and open stairwells (Ballard et al., 2008; P. D. Mills, DeRosier, Ballot, Shepherd, & Bagian, 2008).

508 Limit opening size of operable windows to mitigate jumping risk (e.g., 4").

509 Specify security glazing to meet the risk of the room type (e.g., seclusion room, patient room, activity room, group room, corridor). (This consideration is also relevant under the following category: room layout.)

Why should this be considered? (Rationale) (This cell hyperlinks to references)

Med-Low

507 Provide visual access for staff to outdoor areas to mitigate patient self-harm and detect elopement. (This consideration is also relevant under the following category: site optimization.)

Safe Design Roadmap

Highest

Sort #

What is being discussed? (Design Consideration)

Your Risk Estimate Your Priority

Project Data

Risk Data: Injury - Behavioral Health

A Safety Risk Assessment for Healthcare Facility Environments

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500-Behavioral Health Design Risk Data: Injury - Behavioral Health

A Safety Risk Assessment for Healthcare Facility Environments Glossary/Definitions

The Risk Component Links

What is being discussed? (Design Consideration)

How is this done? Explanations/Clarifications (How Accomplished, Reasons Against)

507 Provide visual access for staff to outdoor areas to mitigate patient self-harm and detect elopement. (This consideration is also relevant under the following category: site optimization.) 508 Limit opening size of operable windows to mitigate jumping risk (e.g., 4").

509 Specify security glazing to meet the risk of the room type (e.g., seclusion room, patient room, activity room, group room, corridor). (This consideration is also relevant under the following category: room layout.) 510 Locate security in close proximity to behavioral health units to allow quick response times.

511 Secure or design to mitigate jumping in any areas where the risk of jumping may be an issue (e.g., roof, balcony, porch, window).

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FGI

Location

Sort #

Location Key: GEN = General Consideration; OL = Overall Layout; IP = Inpatient; D&T = Diagnostic & B = Body (required); Treatment; Rx = Pharmacy; ED = Emergency Department; HIM = Med. Records/Health Information A = Appendix (suggested); Mgmt; OR = Operating; SEC = Seclusion N/I or blank = not included

Building category

Building GEN Envelope/Structu re

N/I

Building GEN Envelope/Structu re

B

Building GEN Envelope/Structu re

B

GEN

Building Layout

B

GEN

Building Layout

N/I

89

500-Behavioral Health Design

515 Control unit doors for entry and exit (e.g., sally port, locked with viewing panel) where warranted by the patient population.

Cost Magnitude

Lowest

Generic Risk Estimate Highest

Based on the model of care and services offered, secure units may be required to protect all users of the facility (Bowers, Banda, & Nijman, 2010; Dobrohotoff & Llewellyn-Jones, 2011; McPhaul et al., 2008; P. D. Mills et al., 2010; Yeager et al., 2005). A balance must exist between a “typically residential” environment and the security required for behavioral health. For example, OSHA suggests comfortable waiting areas to minimize stress, while other suggest the use of signs and symbols that become a “hidden hazard” (Connellan et al., 2013; Dobrohotoff & Llewellyn-Jones, 2011; J. Hunt & Sine, 2009; OSHA, 2013). Factors that may differ between facilities may include patient populations (pediatric, adult, elderly), age groups, diagnosis, private or public, voluntary admission or court committed among others. Research indicates that having separate areas for activity provide patients with control over their surroundings, offering a physical retreat space when feeling threatened (Dobrohotoff & Llewellyn-Jones, 2011). Considerations about family participation might also result in private spaces and waiting areas (Shepley & Pasha, 2013). Based on evaluation of data, numerous papers suggest securing exits (through locks or visual control) and/or minimizing the number of exits to reduce risk of elopement and unauthorized access (Goh, Salmons, & Whittington, 1989; I. Hunt et al., 2010, 2013; McPhaul et al., 2008). Studies indicate that patients who have been identified by staff to be at risk of suicide or self-harm should have limited or no access to uncontrolled from exits (P. D. Mills, Watts, DeRosier, Tomolo, & Bagian, 2012), as elopement from units results in consequences such as loss of treatment, violence to others, self-neglect, selfharm, and suicide (I. Hunt et al., 2010).

513 Balance inpatient unit design between the need for a therapeutic environment and safety.

514 Include spaces with opportunities for both reflection and social interaction on the unit to provide patients a choice of stimulation or privacy.

Why should this be considered? (Rationale) (This cell hyperlinks to references)

Med-Low

512 Include secure psychiatric/behavioral health units for those at risk of self-harm.

Safe Design Roadmap

Med-High

Sort #

What is being discussed? (Design Consideration)

Your Risk Estimate Your Priority

Project Data

Risk Data: Injury - Behavioral Health

A Safety Risk Assessment for Healthcare Facility Environments

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500-Behavioral Health Design Risk Data: Injury - Behavioral Health

A Safety Risk Assessment for Healthcare Facility Environments Glossary/Definitions

The Risk Component Links

What is being discussed? (Design Consideration)

How is this done? Explanations/Clarifications (How Accomplished, Reasons Against)

512 Include secure psychiatric/behavioral health units for those at risk of self-harm.

FGI

Location

Sort #

Location Key: GEN = General Consideration; OL = Overall Layout; IP = Inpatient; D&T = Diagnostic & B = Body (required); Treatment; Rx = Pharmacy; ED = Emergency Department; HIM = Med. Records/Health Information A = Appendix (suggested); Mgmt; OR = Operating; SEC = Seclusion N/I or blank = not included

Building category

IP

Building Layout

B

IP

Unit Layout

B

GEN

Unit Layout

B

IP

Unit Layout

B

513 Balance inpatient unit design between the need for a therapeutic environment and safety.

514 Include spaces with opportunities for both reflection and social interaction on the unit to provide patients a choice of stimulation or privacy.

515 Control unit doors for entry and exit (e.g., sally port, locked with viewing panel) where warranted by the patient population.

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While operational procedures for patient observation may vary, expert opinion suggests that at-risk patients be placed closest to the nursing/team station or near staffing travel patterns to provide greater visibility (J. Hunt & Sine, 2009; Lieberman et al., 2004; McPhaul et al., 2008; Peek-Asa et al., 2009, p. -; Stewart, Ross, Watson, James, & Bowers, 2012; Yeager et al., 2005). Physical layout (corners or other structural blocks) is cited as a barrier to adequate patient observation (J. Hunt & Sine, 2009; P. D. Mills et al., 2012; Stewart et al., 2012). As at-risk patients may be difficult to identify, visibility and accessibility to all patient areas is a primary consideration.

Med-Low

Highest

Med-High

518 Provide nurse stations/team care areas with open access to communication while being safe for staff.

520 Provide visual access for staff to all areas of secure holding (including cameras or mirrors for blind spots) to mitigate self-harm and detect elopement.

Cost Magnitude

Generic Risk Estimate

Studies suggest staff and others can be subject to harm in areas that lack visibility. Where the layout precludes visibility, convex mirrors at the junction of the wall and ceiling can eliminate blind spots (Dobrohotoff & Llewellyn-Jones, 2011; J. Hunt & Sine, 2014; PeekAsa et al., 2009).

517 Design layout to maximize visibility and accessibility to all patient-occupied areas, including treatment spaces (e.g., exam rooms).

519 Provide separate secure rooms for patient at risk for suicide or harm to self and others in the ED (e.g., psychiatric, criminal).

Why should this be considered? (Rationale) (This cell hyperlinks to references)

Highest

516 Design layout to eliminate blind spots and areas where staff can become isolated and overcome; where the layout cannot be changed, reduce the hazards by other means (e.g., corner mirrors or cameras).

Safe Design Roadmap

Highest

Sort #

What is being discussed? (Design Consideration)

Your Risk Estimate Your Priority

Project Data

Risk Data: Injury - Behavioral Health

A Safety Risk Assessment for Healthcare Facility Environments

Copyright 2012-2015 The Center for Health Design. All Rights Reserved.

Expert opinion suggests that nurse stations (team areas) should be designed to afford the least possible barrier between staff and patients. However, staff safety needs to be addressed through the counter design to reduce risk of patient jumping or climbing and offering staff work spaces that are separated from duties of patient care (Andes & Shattell, 2006; J. Hunt & Sine, 2014; Karlin & Zeiss, 2006; Riggs, Due, & Connellan, 2013). Some organizations have moved to a decentralized model that promotes increased circulation of staff (Yeager et al., 2005) Root cause analysis has revealed that inadequate holding areas was a contributing factor to suicide and self-harm in the ED (P. D. Mills et al., 2012). Due to the required level of monitoring, visibility is a priority in secure holding (e.g., ED)/seclusion room location and design (C. Curran, 2005; J. Hunt & Sine, 2014; P. D. Mills et al., 2012). Windows and/or camera surveillance may be required.

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The Risk Component Links

What is being discussed? (Design Consideration)

How is this done? Explanations/Clarifications (How Accomplished, Reasons Against)

516 Design layout to eliminate blind spots and areas where staff can become isolated and overcome; where the layout cannot be changed, reduce the hazards by other means (e.g., corner mirrors or cameras).

FGI

Location

Sort #

Location Key: GEN = General Consideration; OL = Overall Layout; IP = Inpatient; D&T = Diagnostic & B = Body (required); Treatment; Rx = Pharmacy; ED = Emergency Department; HIM = Med. Records/Health Information A = Appendix (suggested); Mgmt; OR = Operating; SEC = Seclusion N/I or blank = not included

Building category

GEN

Unit Layout

A

GEN

Unit Layout

A

IP

Unit Layout

A

ED

Unit Layout

A

GEN

Unit Layout

B

517 Design layout to maximize visibility and accessibility to all patient-occupied areas, including treatment spaces (e.g., exam rooms).

518 Provide nurse stations/team care areas with open access to communication while being safe for staff.

519 Provide separate secure rooms for patient at risk for suicide or harm to self and others in the ED (e.g., psychiatric, criminal). 520 Provide visual access for staff to all areas of secure holding (including cameras or mirrors for blind spots) to mitigate self-harm and detect elopement.

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524 Provide space immediately outside the seclusion room for the response team to manage a patient needing seclusion. (This consideration is also relevant under the following category: room layout.) 525 Provide the seclusion room with the needed space for additional staff when required to contain a patient (i.e., no less than 7' wide and no more than 11' long).

Lowest

526 Design patient rooms with no more than two beds.

Copyright 2012-2015 The Center for Health Design. All Rights Reserved.

Safe Design Roadmap

Cost Magnitude

Generic Risk Estimate Highest Highest Highest

522 Provide ceilings high enough to mitigate the risk of access to ceiling fixtures. (This consideration is also relevant under the following category: building envelope/structure.) 523 Design ceilings with monolithic surfaces to restrict ceiling space access in higher-risk areas.

Med-Low

521 Include secure storage for environmental service items.

Med-High

Sort #

What is being discussed? (Design Consideration)

Your Risk Estimate Your Priority

Project Data

Risk Data: Injury - Behavioral Health

A Safety Risk Assessment for Healthcare Facility Environments

Why should this be considered? (Rationale) (This cell hyperlinks to references) The ability for patients to access ingestible chemicals should be restricted to reduce risk of self-harm (Cardell, Bratcher, & Quinnett, 2009; P. D. Mills et al., 2008). This includes access to EVS supplies and carts that should be stored in secure spaces (Yeager et al., 2005). Ceiling heights should help prevent patients from reaching fixtures that can serve as ligature points and prevent tampering. Most sources recommend a minimum of nine feet (C. Curran, 2005; J. Hunt & Sine, 2014; New York State Office of Mental Health & architecture +, 2012) Ceiling systems with lay-in acoustical tiles that expose plumbing, piping, or ductwork are high risk (Lieberman et al., 2004; New York State, 2009). A plaster/lath, gypsum board, or metal pan system (requiring special tools) is lower risk (C. Curran, 2005; Dobrohotoff & Llewellyn-Jones, 2011; Lieberman et al., 2004). A seclusion room is a high-risk space (J. Hunt & Sine, 2014; New York State Office of Mental Health & architecture +, 2012). Expert opinion from the NAPHS guidelines suggest a lobby or ante-room to include space for a response team to organize, as the patient may be aggressive or struggling upon entry (C. Curran, 2005; J. Hunt & Sine, 2014). Expert opinion suggests space for staff members to contain a patient when necessary (C. Curran, 2005; J. Hunt & Sine, 2014).

Crowding, lack of privacy and loss of control are related to violence on inpatient psychiatric units. A capacity limit for bedroom occupancy is a possible strategy, with private rooms when clinically indicated (Connellan et al., 2013; Dobrohotoff & LlewellynJones, 2011; Shepley & Pasha, 2013).

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A Safety Risk Assessment for Healthcare Facility Environments Glossary/Definitions

The Risk Component Links

What is being discussed? (Design Consideration)

How is this done? Explanations/Clarifications (How Accomplished, Reasons Against)

FGI

Location

Sort #

Location Key: GEN = General Consideration; OL = Overall Layout; IP = Inpatient; D&T = Diagnostic & B = Body (required); Treatment; Rx = Pharmacy; ED = Emergency Department; HIM = Med. Records/Health Information A = Appendix (suggested); Mgmt; OR = Operating; SEC = Seclusion N/I or blank = not included

Building category

521 Include secure storage for environmental service items.

522 Provide ceilings high enough to mitigate the risk of access to ceiling fixtures. (This consideration is also relevant under the following category: building envelope/structure.) 523 Design ceilings with monolithic surfaces to restrict ceiling space access in higher-risk areas.

524 Provide space immediately outside the seclusion room for the response team to manage a patient needing seclusion. (This consideration is also relevant under the following category: room layout.) 525 Provide the seclusion room with the needed space for additional staff when required to contain a patient (i.e., no less than 7' wide and no more than 11' long).

GEN

Unit Layout

N/I

GEN

Room Layout

B

GEN

Room Layout

B

SEC

Unit Layout

N/I

SEC

Room Layout

N/I

IP

Room Layout

B

526 Design patient rooms with no more than two beds.

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528 If doors to patient rooms and/or patient toilet rooms are lockable, provide locks designed to allow emergency access.

Cost Magnitude

Generic Risk Estimate

Why should this be considered? (Rationale) (This cell hyperlinks to references)

Med-Low

527 Specify that support rooms that open into patientaccessible corridors are lockable (e.g., utility, environmental services, administrative).

Safe Design Roadmap

Ancillary spaces such as conference rooms or interview rooms should be secured when not in use to prevent unauthorized patient entry (Cardell et al., 2009; J. Hunt & Sine, 2014). Environmental service rooms should be self-locking (Peter D. Mills et al., 2010). Some experts suggest redundant systems such as self-closing and locking doors to ensure staff safety or classroom style lock as an additional safeguard to help protect against a patient inadvertently being locked in a room. According to one author, while these interventions can prevent unauthorized patient entry, they also need to be balanced against staff safety due to the increased potential for staff and patients being in the room together when the door is closed (P. D. Mills et al., 2010).

Med-Low

Sort #

What is being discussed? (Design Consideration)

Your Risk Estimate Your Priority

Project Data

Risk Data: Injury - Behavioral Health

A Safety Risk Assessment for Healthcare Facility Environments

Locks may be required to prevent unauthorized entry into rooms or to afford privacy, but they can also present a hazard if staff cannot access the room (Dobrohotoff & LlewellynJones, 2011). Self-harm can occur when patients are allowed privacy in the toilet or other private areas and lock doors behind them. (Bowers et al., 2010). Some suggest unlockable doors (Cardell et al., 2009), but when not possible, classroom style locks may be needed (J. Hunt & Sine, 2009).

Highest

529 Design door swings to prevent a patient from barricading a room from the inside.

Copyright 2012-2015 The Center for Health Design. All Rights Reserved.

Numerous studies reference the door as a potential barricade, leading to risk of self-harm and harm to others (Dobrohotoff & Llewellyn-Jones, 2011; J. Hunt & Sine, 2009; New York State Office of Mental Health & architecture +, 2012). This needs to be balanced with the need to prevent obstructions associated with fire codes and egress width, as well as the potential for alcoves that can obscure visibility (J. Hunt & Sine, 2009, 2014). Options may also include wicket doors or inswinging door design that accommodates plans for easy removal, if needed (New York State Office of Mental Health & architecture +, 2012).

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A Safety Risk Assessment for Healthcare Facility Environments Glossary/Definitions

The Risk Component Links

What is being discussed? (Design Consideration)

How is this done? Explanations/Clarifications (How Accomplished, Reasons Against)

FGI

Location

Sort #

Location Key: GEN = General Consideration; OL = Overall Layout; IP = Inpatient; D&T = Diagnostic & B = Body (required); Treatment; Rx = Pharmacy; ED = Emergency Department; HIM = Med. Records/Health Information A = Appendix (suggested); Mgmt; OR = Operating; SEC = Seclusion N/I or blank = not included

Building category

527 Specify that support rooms that open into patientaccessible corridors are lockable (e.g., utility, environmental services, administrative).

528 If doors to patient rooms and/or patient toilet rooms are lockable, provide locks designed to allow emergency access.

GEN

Room Layout

N/I

IP

Room Layout

N/I

GEN

Room Layout

B

529 Design door swings to prevent a patient from barricading a room from the inside.

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531 Select door handles and other hardware (closers, hinges) to reduce possible anchor points for hanging.

533 Consider materials to reduce noise.

Med-Low

Highest

532 Eliminate doors with hold-open devices and self-closers that could be used as an anchor point for hanging.

Copyright 2012-2015 The Center for Health Design. All Rights Reserved.

Safe Design Roadmap

Cost Magnitude

Generic Risk Estimate Highest

530 Design patient toilet room doors in patient rooms either to reduce hanging points or eliminate doors entirely if adequate patient privacy can be maintained.

Highest

Sort #

What is being discussed? (Design Consideration)

Your Risk Estimate Your Priority

Project Data

Risk Data: Injury - Behavioral Health

A Safety Risk Assessment for Healthcare Facility Environments

Why should this be considered? (Rationale) (This cell hyperlinks to references) It is a tradeoff that good visibility may impinge on patients’ privacy, most notably around patient room bathrooms and toilet areas in treatment spaces (e.g., emergency), where hangings often occur (Dobrohotoff & Llewellyn-Jones, 2011; Gournay & Bowers, 2000; P. D. Mills et al., 2012; P. D. Mills, Watts, & Hemphill, 2014). Toilet room doors are often a risk, and some organizations use accordion doors, doors with slanted tops, or eliminate doors entirely in private room situations or where not needed by code (Cardell et al., 2009; P. D. Mills et al., 2008; Yeager et al., 2005). Non-lever handles, handles that face down, recessed grip handles, push/pull, and ligatureresistant handles are all solutions suggested to mitigate the door handle as a point for hanging (ECRI Institute & The Institute for Safe Medication Practices, 2007; J. Hunt & Sine, 2014; P. D. Mills et al., 2010, 2008, 2012; New York State Office of Mental Health & architecture +, 2012). Doors are often cited as a location for hanging. Door closer devices should be carefully considered (C. Curran, 2005; J. Hunt & Sine, 2014; New York State Office of Mental Health & architecture +, 2012) and when used, mounted on the public side of a door instead of the private patient side (J. Hunt & Sine, 2014; Lieberman et al., 2004; New York State Office of Mental Health & architecture +, 2012). Door hinges should be the continuous piano style that extend from the top of the door to the bottom in an unbroken manner (Lipscomb et al., 2006; McPhaul et al., 2008; P. D. Mills et al., 2010, 2008; New York State Office of Mental Health & architecture +, 2012; New York State, 2009) OSHA-based design guidelines suggest the use of absorptive wall panels in day rooms may reduce anxiety and stress (Lipscomb et al., 2006). Another study suggests hard-surface flooring in hallways contributes to noise, as well as negative perceptions of the environment (Dobrohotoff & Llewellyn-Jones, 2011).

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A Safety Risk Assessment for Healthcare Facility Environments Glossary/Definitions

The Risk Component Links

What is being discussed? (Design Consideration)

How is this done? Explanations/Clarifications (How Accomplished, Reasons Against)

FGI

Location

Sort #

Location Key: GEN = General Consideration; OL = Overall Layout; IP = Inpatient; D&T = Diagnostic & B = Body (required); Treatment; Rx = Pharmacy; ED = Emergency Department; HIM = Med. Records/Health Information A = Appendix (suggested); Mgmt; OR = Operating; SEC = Seclusion N/I or blank = not included

Building category

530 Design patient toilet room doors in patient rooms either to reduce hanging points or eliminate doors entirely if adequate patient privacy can be maintained. IP

Room Layout

N/I

GEN

Interior Design/Finishes

B

GEN

Interior Design/Finishes

B

GEN

Interior Design/Finishes

N/I

531 Select door handles and other hardware (closers, hinges) to reduce possible anchor points for hanging.

532 Eliminate doors with hold-open devices and self-closers that could be used as an anchor point for hanging.

533 Consider materials to reduce noise.

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535 Incorporate room details designed to eliminate sharp edges and to have rounded outside corners.

538 Select "no gap" grab bars to eliminate suspension points for hanging.

Interior finishes should take into account impact resistance (e.g., wall construction), toxicity (e.g., paint) and the properties to reduce concealment of contraband or weapons that can be used for self-harm (e.g., seamless flooring with an integral cove, moldings) (C. Curran, 2005; ECRI Institute & The Institute for Safe Medication Practices, 2007; J. Hunt & Sine, 2009, 2014). According to experts, edges and corners in patient areas (e.g., plumbing, bathroom accessories, furniture) should be rounded off to eliminate self-harm and harm to others (C. Curran, 2005; McPhaul et al., 2008; New York State Office of Mental Health & architecture +, 2012). Several sources suggest mirrors should be made of stainless steel, unbreakable glass, polycarbonate or acrylic to reduce the risk of broken glass becoming a weapon (Dobrohotoff & Llewellyn-Jones, 2011; ECRI Institute & The Institute for Safe Medication Practices, 2007; J. Hunt & Sine, 2009, 2014; Lieberman et al., 2004).

Highest

537 Specify bathroom hardware and accessories to reduce risk of self-harm (anchor points) and harm to others (fixture parts becoming weapons).

Why should this be considered? (Rationale) (This cell hyperlinks to references)

Hard plastic paper towel, toilet paper, toiletry shelves, and soap dispensers can be broken resulting in sharp pieces of plastic that can be used as weapons. They can also be used for hanging. Soap dishes and toilet paper holders should be recessed (Cardell et al., 2009; J. Hunt & Sine, 2009; P. D. Mills et al., 2014)and If possible, the shower stalls should be designed so that a shower curtain is not needed (J. Hunt & Sine, 2009).

Highest

Highest

536 Specify mirrors made of non-breakable material.

Safe Design Roadmap

Cost Magnitude

Generic Risk Estimate Med-Low

534 Consider material selection (e.g., breakability, breathability, toxicity, flame retardence) to reduce all forms of self-harm.

Med-High

Sort #

What is being discussed? (Design Consideration)

Your Risk Estimate Your Priority

Project Data

Risk Data: Injury - Behavioral Health

A Safety Risk Assessment for Healthcare Facility Environments

Hanging attempts occur with objects below waist height (J. Hunt & Sine, 2009; Lieberman et al., 2004), including components such as grab bars. The elimination of ligature points in grab bars is often cited as a mitigation technique (J. Hunt & Sine, 2009; P. D. Mills et al., 2012; New York State Office of Mental Health & architecture +, 2012; New York State, 2009; Yeager et al., 2005).

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A Safety Risk Assessment for Healthcare Facility Environments Glossary/Definitions

The Risk Component Links

What is being discussed? (Design Consideration)

How is this done? Explanations/Clarifications (How Accomplished, Reasons Against)

534 Consider material selection (e.g., breakability, breathability, toxicity, flame retardence) to reduce all forms of self-harm.

535 Incorporate room details designed to eliminate sharp edges and to have rounded outside corners.

FGI

Location

Sort #

Location Key: GEN = General Consideration; OL = Overall Layout; IP = Inpatient; D&T = Diagnostic & B = Body (required); Treatment; Rx = Pharmacy; ED = Emergency Department; HIM = Med. Records/Health Information A = Appendix (suggested); Mgmt; OR = Operating; SEC = Seclusion N/I or blank = not included

Building category

GEN

Interior Design/Finishes

N/I

GEN

Interior Design/Finishes

B

GEN

Interior Design/Finishes

B

GEN

Interior Design/Finishes

B

GEN

Interior Design/Finishes

B

536 Specify mirrors made of non-breakable material.

537 Specify bathroom hardware and accessories to reduce risk of self-harm (anchor points) and harm to others (fixture parts becoming weapons).

538 Select "no gap" grab bars to eliminate suspension points for hanging.

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541 Install artwork in a manner that does not provide potential hazards to patients (e.g., non-breakable frame/covering, secured with tamper-resistant fasteners).

542 Design/select furnishings and/or furniture (by physical attachment or weight) to mitigate self-harm (barricade, suicide) and harm to others (projectiles, entrapment). (This consideration is also relevant under the following category: site optimization [exterior furniture].)

Copyright 2012-2015 The Center for Health Design. All Rights Reserved.

Safe Design Roadmap

Cost Magnitude

Generic Risk Estimate Med-Low Med-Low

540 Affix wall and floor finishes, ceilings, molding and other interior details to limit the ability of patient to hide contraband items.

Med-High

539 Provide fixed, non-adjustable shelves or hooks that support no more than 4 lbs. (and do not have rods or hangers) used for patient-accessible storage.

Highest

Sort #

What is being discussed? (Design Consideration)

Your Risk Estimate Your Priority

Project Data

Risk Data: Injury - Behavioral Health

A Safety Risk Assessment for Healthcare Facility Environments

Why should this be considered? (Rationale) (This cell hyperlinks to references) Research indicates that common environmental risk factors include potential anchor points for hanging - one of the most frequently used methods of self-harm. The use of clothes rods and hangers in behavioral health areas is discouraged (Cardell et al., 2009; J. Hunt & Sine, 2009; Lieberman et al., 2004; New York State Office of Mental Health & architecture +, 2012). Guidelines reference concealment of weapons as a risk (J. Hunt & Sine, 2014; New York State Office of Mental Health & architecture +, 2012). One safety advisory suggests suggest the consideration of permanent wall and ceiling treatments, moldings, and floors to prevent concealment of harmful items such as razor blades, matches, and drugs (ECRI Institute & The Institute for Safe Medication Practices, 2007). It is possible that artwork, frames and glass shards can be used as a weapon for self-harm or harm against others (P. D. Mills et al., 2010). One study recommended a proactive approach to identify possible risk rather than assuming the risk did not exist, even if using something like using glass as a weapon had not been documented as a safety event (Yeager et al., 2005). As with windows, tempered glass does not yield large shards of glass when broken, but does not stay in the frame; laminated glass will stay in the frame, but will yield shards. Polycarbonate sheets will satisfy both of these requirements, (provided that the stops are deep enough to account for the amount of deflection of large pieces) (J. Hunt & Sine, 2009). Furniture (both interior and exterior ) can be used for patient to harm themselves or throw at/strike staff or as a climbing tool to facilitate elopement (ECRI Institute & The Institute for Safe Medication Practices, 2007; Gunnell, Bennewith, Hawton, Simkin, & Kapur, 2005; J. Hunt & Sine, 2009; McPhaul et al., 2008; New York State Office of Mental Health & architecture +, 2012).

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A Safety Risk Assessment for Healthcare Facility Environments Glossary/Definitions

The Risk Component Links

What is being discussed? (Design Consideration)

How is this done? Explanations/Clarifications (How Accomplished, Reasons Against)

FGI

Location

Sort #

Location Key: GEN = General Consideration; OL = Overall Layout; IP = Inpatient; D&T = Diagnostic & B = Body (required); Treatment; Rx = Pharmacy; ED = Emergency Department; HIM = Med. Records/Health Information A = Appendix (suggested); Mgmt; OR = Operating; SEC = Seclusion N/I or blank = not included

Building category

539 Provide fixed, non-adjustable shelves or hooks that support no more than 4 lbs. (and do not have rods or hangers) used for patient-accessible storage.

GEN

Interior Design/Finishes

B

540 Affix wall and floor finishes, ceilings, molding and other interior details to limit the ability of patient to hide contraband items.

GEN

Interior Design/Finishes

N/I

GEN

Interior Design/Finishes

N/I

GEN

Furnishings

B

541 Install artwork in a manner that does not provide potential hazards to patients (e.g., non-breakable frame/covering, secured with tamper-resistant fasteners).

542 Design/select furnishings and/or furniture (by physical attachment or weight) to mitigate self-harm (barricade, suicide) and harm to others (projectiles, entrapment). (This consideration is also relevant under the following category: site optimization [exterior furniture].)

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Cost Magnitude

Generic Risk Estimate Highest

Plumbing fixtures such as shower heads should be flush or slanted to avoid becoming a means for a hanging attempt, while toilets should be selected and installed to avoid gaps at the wall or floor that can become ligature points. Button flushers and integral seats are also suggested for toilets. (Cardell et al., 2009; C. Curran, 2005; J. Hunt & Sine, 2014; Lieberman et al., 2004; P. D. Mills et al., 2014; Yeager et al., 2005).

Highest

544 Design plumbing with concealed pipes to minimize risk of becoming ligature points.

Why should this be considered? (Rationale) (This cell hyperlinks to references)

P-traps, supply pipes under lavatories, flush valves for toilets and faucets are potential attachment points for hanging (Cardell et al., 2009; Gunnell et al., 2005; J. Hunt & Sine, 2009, 2014; Kahn & Antonucci., 1980; Lieberman et al., 2004; Yeager et al., 2005).

Highest

543 Select flush-mount plumbing fixtures (e.g., shower heads, toilets) where possible, to minimize risk of becoming ligature points.

Safe Design Roadmap

Research indicates that common environmental risk factors include potential anchor points for hanging - one of the most frequently used methods of self-harm. In higher risk interior areas, teams should consider whether light fixtures should be recessed/flush mounted, security type with fully enclosed frames, polycarbonate or similar, lenses and security fasteners or have substantial lenses securely anchored in place with frames secured by tamper resistant screws (E. T. Curran, Hamilton, Monaghan, McGinlay, & Thakker, 2006; Gunnell et al., 2005; J. Hunt & Sine, 2009, 2014; New York State Office of Mental Health & architecture +, 2012). Outdoor areas should be designed with vandal proof bulkhead fittings (Curran 2005).

Highest

Sort #

What is being discussed? (Design Consideration)

Your Risk Estimate Your Priority

Project Data

Risk Data: Injury - Behavioral Health

A Safety Risk Assessment for Healthcare Facility Environments

Research indicates that common environmental risk factors include potential anchor points for hanging - one of the most frequently used methods of self-harm.. Sprinkler head design should minimize the opportunity for attachment (Cardell et al., 2009; ECRI Institute & The Institute for Safe Medication Practices, 2007; Lieberman et al., 2004; P. D. Mills et al., 2012; New York State Office of Mental Health & architecture +, 2012). They should break away at less than a 50 pound load (J. Hunt & Sine, 2009).

545 Select tamper-resistant light fixtures and other appurtenances.

546 Secure sprinkler heads from tampering (flush or a breakaway design that does not activate the head).

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A Safety Risk Assessment for Healthcare Facility Environments Glossary/Definitions

The Risk Component Links

What is being discussed? (Design Consideration)

How is this done? Explanations/Clarifications (How Accomplished, Reasons Against)

543 Select flush-mount plumbing fixtures (e.g., shower heads, toilets) where possible, to minimize risk of becoming ligature points.

544 Design plumbing with concealed pipes to minimize risk of becoming ligature points.

FGI

Location

Sort #

Location Key: GEN = General Consideration; OL = Overall Layout; IP = Inpatient; D&T = Diagnostic & B = Body (required); Treatment; Rx = Pharmacy; ED = Emergency Department; HIM = Med. Records/Health Information A = Appendix (suggested); Mgmt; OR = Operating; SEC = Seclusion N/I or blank = not included

Building category

GEN

Plumbing

B

GEN

Mechanical (HVAC)/Electrical

B

GEN

Mechanical (HVAC)/Electrical

B

GEN

Mechanical (HVAC)/Electrical

B

545 Select tamper-resistant light fixtures and other appurtenances.

546 Secure sprinkler heads from tampering (flush or a breakaway design that does not activate the head).

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549 Provide communication systems or alarms to mitigate risk of harm to staff.

Highest

548 Incorporate all HVAC components (e.g., air grilles, thermostats, under-window heating and cooling units) to reduce ligature attachments and possible patient tampering that could lead to hanging or harm to self or others.

Highest

Med-High

547 Eliminate or control electrical outlets to mitigate selfharm.

Med-Low

550 Provide video surveillance systems.

Copyright 2012-2015 The Center for Health Design. All Rights Reserved.

Safe Design Roadmap

Cost Magnitude

Generic Risk Estimate

Sort #

What is being discussed? (Design Consideration)

Your Risk Estimate Your Priority

Project Data

Risk Data: Injury - Behavioral Health

A Safety Risk Assessment for Healthcare Facility Environments

Why should this be considered? (Rationale) (This cell hyperlinks to references) Many papers suggest that traditional electrical outlets should not be used in behavioral health areas (Cardell et al., 2009; Dobrohotoff & Llewellyn-Jones, 2011; ECRI Institute & The Institute for Safe Medication Practices, 2007; J. Hunt & Sine, 2014; New York State Office of Mental Health & architecture +, 2012). Some suggest any outlets provided include a Ground fault Circuit Interrupter that can be controlled without staff entering the room (J. Hunt & Sine, 2014; New York State Office of Mental Health & architecture +, 2012). Common environmental risk factors include potential anchor points for hanging - one of the most frequently used methods of self-harm. These include HVAC terminal devices and covers, and thermostats, as well as vents and grilles that should be fastened with security screws, locks or tamper resistant fasteners. Heat/smoke detectors should be flush ceiling mounted. (C. Curran, 2005; ECRI Institute & The Institute for Safe Medication Practices, 2007; New York State Office of Mental Health & architecture +, 2012). Numerous studies correlate the relationship between attacks and threats of attack on staff with the use of alarm systems (C. Curran, 2005; Dobrohotoff & Llewellyn-Jones, 2011; J. Hunt & Sine, 2009, 2014; Lipscomb et al., 2006; McPhaul et al., 2008; OSHA, 2013; PeekAsa et al., 2009). This may include panic buttons, hand-held alarms or noise devices, cellular phones and private channel radios where risk is apparent or may be anticipated. Experts suggest the use of video surveillance in high-risk areas (indoor and outdoor) to deter elopement and unauthorized access (I. Hunt et al., 2010; J. Hunt & Sine, 2014; OSHA, 2013; Peek-Asa et al., 2009; Riggs et al., 2013). These should be installed where public safety is a greater concern than patient privacy or where privacy would not be expected and should not be accessible by patients. However, as some note, it is not reasonable to expect staff to reliably monitor a camera for long periods, so better to make the environment safe enough so there is not a reliance on technology alone (P. D. Mills et al., 2010; Peek-Asa et al., 2009).

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A Safety Risk Assessment for Healthcare Facility Environments Glossary/Definitions

The Risk Component Links

What is being discussed? (Design Consideration)

How is this done? Explanations/Clarifications (How Accomplished, Reasons Against)

FGI

Location

Sort #

Location Key: GEN = General Consideration; OL = Overall Layout; IP = Inpatient; D&T = Diagnostic & B = Body (required); Treatment; Rx = Pharmacy; ED = Emergency Department; HIM = Med. Records/Health Information A = Appendix (suggested); Mgmt; OR = Operating; SEC = Seclusion N/I or blank = not included

Building category

547 Eliminate or control electrical outlets to mitigate selfharm.

548 Incorporate all HVAC components (e.g., air grilles, thermostats, under-window heating and cooling units) to reduce ligature attachments and possible patient tampering that could lead to hanging or harm to self or others.

GEN

Mechanical (HVAC)/Electrical

B

GEN

Mechanical (HVAC)/Electrical

N/I

GEN

Technology Integration

B

GEN

Technology Integration

B,A

549 Provide communication systems or alarms to mitigate risk of harm to staff.

550 Provide video surveillance systems.

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551 Ensure telephones accessible by patients are specified with either safety cords or cordless/“hands-free” equipment.

Copyright 2012-2015 The Center for Health Design. All Rights Reserved.

Safe Design Roadmap

Cost Magnitude

Generic Risk Estimate Med-Low

Sort #

What is being discussed? (Design Consideration)

Your Risk Estimate Your Priority

Project Data

Risk Data: Injury - Behavioral Health

A Safety Risk Assessment for Healthcare Facility Environments

Why should this be considered? (Rationale) (This cell hyperlinks to references) Telephones should not be left with suicidal patient without supervision as the phone and/or cords can be used for self-harm and harm against staff (Cardell et al., 2009; C. Curran, 2005; Gunnell et al., 2005; J. Hunt & Sine, 2014; P. D. Mills et al., 2014).

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The Risk Component Links

What is being discussed? (Design Consideration)

How is this done? Explanations/Clarifications (How Accomplished, Reasons Against)

551 Ensure telephones accessible by patients are specified with either safety cords or cordless/“hands-free” equipment.

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GEN

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FGI

Location

Sort #

Location Key: GEN = General Consideration; OL = Overall Layout; IP = Inpatient; D&T = Diagnostic & B = Body (required); Treatment; Rx = Pharmacy; ED = Emergency Department; HIM = Med. Records/Health Information A = Appendix (suggested); Mgmt; OR = Operating; SEC = Seclusion N/I or blank = not included

Building category

Technology Integration

A

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Security Risk Data

Home

Design Considerations: Security

A Safety Risk Assessment for Healthcare Facility Environments

Safe Design Roadmap

Project Data

The Risk Component Links

Glossary/Definitions

Certain patient populations are more at risk than others from a security and elopement perspective. Areas such as the infant birthing center are at security risk for kidnapping, whereas with other areas, such as behavioral health, patients may be at risk for elopement, i.e., where they wander away, run away or escape, prior to their scheduled discharge. Assessing the security/elopement vulnerability of each patient population will help assess the consequent requirements of the physical environment. Security-sensitive patient areas should be identified by taking into account the risk that particular patient conditions in the unit pose to elopement/security breach.

A written comprehensive security plan should be developed for normal and contingent operations. This plan should address the overall site, each building and all securitysensitive areas (as relevant to the scope of the project). This plan should take a layered approach to access control, including (but not limited to) security sensitive zones, control points, circulation routes and required egress paths. This plan should consider any existing institutional security plans, if available, and include any impact this project may have on such plans.

It is essential to identify areas requiring the segregation of authorized and unauthorized persons and areas requiring the segregation of public, patient and staff areas. Highly sensitive areas are limited to vetted and authorized staff. These areas frequently include the pharmacy and narcotic storage spaces, hazardous materials, plant utility and information technology infrastructure and areas housing personal health information (PHI). It is important to remember that security considerations for such areas should be addressed alongside regulatory oversight, standards and guidelines, since each area may have specific concerns that must be taken into account. Such authorized staff-only areas in highly sensitive locations should be identified. A clear understanding of areas which require the segregation of authorized and non-authorized personnel is important to determine the level of security, and suitable security measures.

During the overall planning of the project it is also important to think about the security risk to the healthcare facility "during" construction. This can be a threat not just to property, but in the case of renovation projects, to the existing patients and staff.

Security considerations also include protection at the perimeter of the property, at the building perimeter and inside the building. A clear understanding of the different points of access, circulation routes, different patient/visitor/staff/admin zones, and egress paths for regular and emergent situations is necessary before putting security measures in place. Considering all vulnerabilities at an overall planning/policy level can help to create a safe and secure environment.

Security incidents may cause actual harm to patients, family and staff on various severity levels ranging from minor injuries to injuries or harm needing medical treatment, and to disabilities and sentinel events. It is important to evaluate the likelihood and severity of the probable harm caused by security incidents in various areas in one facility including the highly sensitive areas at early design stages. This will help to focus efforts on those security issues that may cause most harm. Is the likelihood rare or almost certain? Is the consequence negligible or minor injury or a sentinel event?

Copyright 2012-2015 The Center for Health Design. All Rights Reserved.

A security plan for the construction phase should be developed that is risk appropriate for the environment and function of the project space and includes: a. A description of the impact of demolition and phasing on existing site functions and protection strategies and design interventions; b. An assessment of the need for temporary security barriers such as fencing and security systems, including intrusion detection and video surveillance systems; c. A schedule for installation of security systems for completion during early move-in activities to allow for protection of the facility and equipment.

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Home

Safe Design Roadmap

Project Data

Consequence

A panel of experts created a generic level of risk, but this should be considered with respect to your own organization and patient demographic. Likelihood Rare

A Safety Risk Assessment for Healthcare Facility Environments

The Risk Component Links

Glossary/Definitions

You might consider a typical “heat map” of risk throughout your decision process. A sample is shown.

Unlikely

Possible

Likely

Almost Certain

Sentinel event Partial disability Medical treatment First aid No injury or disability

Evaluate historical data to ascertain all conditions (e.g., service type, patient populations) that contribute to self-harm in both inpatient and outpatient areas.

Location/Unit Type

Adverse event/rate

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Past performance does not guarantee future results, but this may help identify the likelihood of events, specific to the organization. Are there patterns of vulnerability? Subject Matter Expert Consulted (Name)

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Title/Role

Data Source

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Cost Magnitude Select Select

Select

Select

Select

Select

Your Priority Select Select Select Select

Select

Select Select

Select

Select

Select

Generic Risk Estimate Med-High Med-High

Copyright 2012-2015 The Center for Health Design. All Rights Reserved.

Select

606 Identify controllable entry points to the campus for emergency/ heightened security situations.

Select

604 Consider a single unified or integrated system for access control, video surveillance and, when appropriate, parking access and egress, debit card functions and time and attendance needs. 605 Enable the security system to completely shut down vehicular and pedestrian access if needed.

Safe Design Roadmap

Med-High

603 Provide an emergency communication system with direct communication capability with security, law enforcement or other mechanisms to obtain immediate assistance.

Med-Low

602 Provide an emergency radio communication system in each facility, which operates independently of the building's service and emergency power systems.

Med-Low

601 Address the facility's role in responding to internal and external emergencies on its own, or in coordination with local emergency response or public health authorities based on the assessed risk.

Med-High

Sort #

What is being discussed? (Design Consideration)

Your Risk Estimate

Project Data

Risk Data: Security

A Safety Risk Assessment for Healthcare Facility Environments

Why should this be considered? (Rationale) (This cell hyperlinks to references) Situations requiring emergency planning can be man-made (terrorism, pandemics, etc.), accidental (fires, hazardous materials), or natural (earthquakes, hurricanes etc.). To respond to emergencies, coordination between multiple healthcare facilities may be needed with additional support from public health authorities. To respond to emergencies, coordination and communication between multiple healthcare facilities and between teams is very important. The emergency communication should not rely on the building infrastructure (such as power systems), which may have been compromised due to the emergency situations. To respond to emergencies, coordination and communication between healthcare facilities and other public service providers is essential. The emergency communication should not rely on the building infrastructure (such as power systems), which may have been compromised due to the emergency situations. A challenge for security is the use of multiple electronic systems which do not synchronize or communicate with each other, or are not compatible with the physical environment conditions (Yow, 2012). Situations requiring emergency planning can be man-made (terrorism, pandemics, etc.), accidental (fires, hazardous materials), or natural (earthquakes, hurricanes etc.). Complete lockdown of facility site including shut down of access and egress systems may be needed, depending on the emergency situation. Situations requiring emergency planning can be man-made (terrorism, pandemics, etc.), accidental (fires, hazardous materials), or natural (earthquakes, hurricanes etc.). Depending on the emergency situation, access to the facility site may need to be controlled. The controlled access points should be identified ahead of time to ensure proper response during emergency situations.

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Risk Data: Security

A Safety Risk Assessment for Healthcare Facility Environments Glossary/Definitions

The Risk Component Links

What is being discussed? (Design Consideration)

How is this done? Explanations/Clarifications (How Accomplished, Reasons Against)

601 Address the facility's role in responding to internal and external emergencies on its own, or in coordination with local emergency response or public health authorities based on the assessed risk.

B = Body (required); A = Appendix (suggested); N/I or blank = not included

Location

Sort #

Location Key: GEN = General Consideration; OL = Overall Layout; IP = Inpatient; D&T = Diagnostic & Treatment; Rx = Pharmacy; ED = Emergency Department; HIM = Med. Records/Health Information Mgmt; OR = Operating; SEC = Seclusion

FGI

112

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Building category

GEN Site Optimization

602 Provide an emergency radio communication system in each facility, which operates independently of the building's service and emergency power systems. 603 Provide an emergency communication system with direct communication capability with security, law enforcement or other mechanisms to obtain immediate assistance. 604 Consider a single unified or integrated system for access control, video surveillance and, when appropriate, parking access and egress, debit card functions and time and attendance needs. 605 Enable the security system to completely shut down vehicular and pedestrian access if needed.

GEN

Technology Integration

GEN

Technology Integration

GEN

Technology Integration

GEN

Technology Integration

606 Identify controllable entry points to the campus for emergency/ heightened security situations. GEN Site Optimization

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A

B

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Cost Magnitude Select Select Select Select

Select

Select

Your Priority Select Select Select Select

Select

Select Select Select

Select

Generic Risk Estimate Med-Low Highest Highest

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Select

612 Maximize visibility and line of sight into areas of the parking lot.

Select

611 Position attendant booth, parking offices or security stations (if used) where attendants/officers can directly monitor activity in the parking area.

Select

610 Design parking facilities according to specific security considerations including: limiting and controlling entries/exits; protective lighting; physical protective barriers; and video surveillance.

Med-Low

608 Provide adequate and unobstructed lighting to enable surveillance of the grounds surrounding a healthcare facility. (This consideration is also related to the category: lighting.) 609 Avoid/eliminate places of potential concealment/habitation in the landscape and maximize visibility (unobstructed sightlines).

Safe Design Roadmap

Med-Low

607 Limit and control points of entry into the site (vehicular and pedestrian).

Med-High

Sort #

What is being discussed? (Design Consideration)

Your Risk Estimate

Project Data

Risk Data: Security

A Safety Risk Assessment for Healthcare Facility Environments

Why should this be considered? (Rationale) (This cell hyperlinks to references) The first level of protection of the healthcare facility is at the perimeter of the site itself (IAHSS, 2012). Securing the perimeter with controlled entry points can reduce security related risks to patients, staff and family within the facility. Sufficient lighting is a key component of the surveillance of the site, grounds, and parking lots/structures for the protection of a facility building perimeter. This can help mitigate risks, as well as prompt action on any breaches identified.

Places of potential concealment/habitation in the areas surrounding a healthcare building may impede visual surveillance and contribute to heightened risk of security breaches. Minimizing the existence of these types of places may help protect a building’s perimeter by enhancing the surveillance of the surrounding site, grounds, and parking structures. Surface parking lots and multilevel parking structures can be both scary and dangerous. Control of vehicular access and pedestrian egress, protective barriers, and lighting, are key effective measures used in practice in creating a secure parking facility, both physically and psychologically. In addition, adequate surveillance of the site, grounds, and parking structures can help mitigate risks, as well as prompt immediate action on any breaches identified. To protect the building at its perimeter, adequate direct visual surveillance of the site, grounds, and parking structures is needed. This can help mitigate risks, as well as prompt action on any breaches identified. To protect the building at its perimeter, adequate surveillance of the site, grounds, and parking structures is needed (including non-technological means). Direct line of sight from staff to parking areas may help mitigate risks, as well as prompt action on any breaches identified.

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Risk Data: Security

A Safety Risk Assessment for Healthcare Facility Environments Glossary/Definitions

The Risk Component Links

What is being discussed? (Design Consideration)

How is this done? Explanations/Clarifications (How Accomplished, Reasons Against)

607 Limit and control points of entry into the site (vehicular and pedestrian).

Building category

GEN Site Optimization

608 Provide adequate and unobstructed lighting to enable surveillance of the grounds surrounding a healthcare facility. (This consideration is also related to the category: lighting.) 609 Avoid/eliminate places of potential concealment/habitation in the landscape and maximize visibility (unobstructed sightlines).

GEN Site Optimization

GEN Site Optimization

610 Design parking facilities according to specific security considerations including: limiting and controlling entries/exits; protective lighting; physical protective barriers; and video surveillance.

GEN Site Optimization

611 Position attendant booth, parking offices or security stations (if used) where attendants/officers can directly monitor activity in the parking area.

GEN Site Optimization

612 Maximize visibility and line of sight into areas of the parking lot.

Copyright 2012-2015 The Center for Health Design. All Rights Reserved.

B = Body (required); A = Appendix (suggested); N/I or blank = not included

Location

Sort #

Location Key: GEN = General Consideration; OL = Overall Layout; IP = Inpatient; D&T = Diagnostic & Treatment; Rx = Pharmacy; ED = Emergency Department; HIM = Med. Records/Health Information Mgmt; OR = Operating; SEC = Seclusion

FGI

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GEN Site Optimization

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Select

Select

Select

Select

Cost Magnitude

Safe Design Roadmap

Select

Your Priority Select Select Select Select

Select Select Select

Generic Risk Estimate Med-High Med-High

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Select

617 Implement segregation of authorized and unauthorized visitors in security-sensitive patient areas.

Select

616 Put in place penetration-resistant protective measures that extend from solid floor to solid ceiling or roof in the building envelope for highly security-sensitive areas.

Select

615 Limit and control points of entry into and exit from the building, while ensuring vehicular and pedestrian safety.

Highest

614 Locate security officer posts and/or police officer workstations, when accommodated in a building, to maximize visibility at public entrances, waiting areas, registration and information areas.

Med-High

613 Avoid/eliminate dead-end parking areas and areas of concealment.

Highest

Sort #

What is being discussed? (Design Consideration)

Your Risk Estimate

Project Data

Risk Data: Security

A Safety Risk Assessment for Healthcare Facility Environments

Why should this be considered? (Rationale) (This cell hyperlinks to references) To protect the building at its perimeter, adequate surveillance of the site, grounds, and parking structures is needed. Due to the lack of direct sight lines, it may be difficult for security staff to monitor dead-end parking areas and areas of concealment. Eliminating such areas can help mitigate risks, as well as prompt action on any breaches identified. The ability to direct visual monitoring of areas associated with high traffic can help to mitigate security risks, as well as enable prompt action on any breaches identified.

Protection at the building perimeter relates to the different points of access including doors, windows, or other openings. Protective elements may also include access-control hardware, intrusion detection, video surveillance, use of protective glazing materials, or personnel for control and screening at access points. Different facilities may adopt different strategies, and levels of technology, to secure the building perimeter, but the fundamental concern is limiting and controlling the different points of access, which allows more concentrated and more effective use of protective measures. Highly security sensitive areas such as pharmacies or areas with Protected Healthcare Information (PHI) are at higher risk for burglary and other security breaches. To protect these security sensitive areas from unauthorized entrances, their perimeters should be strengthened through penetration-resistant measures. In addition to securing the perimeter, a key component of preventing unauthorized access to security sensitive areas is the segregation of authorized and unauthorized visitors. The physical segregation may help to prevent unauthorized visitors from accessing security sensitive areas.

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Risk Data: Security

A Safety Risk Assessment for Healthcare Facility Environments Glossary/Definitions

The Risk Component Links

What is being discussed? (Design Consideration)

How is this done? Explanations/Clarifications (How Accomplished, Reasons Against)

B = Body (required); A = Appendix (suggested); N/I or blank = not included

Location

Sort #

Location Key: GEN = General Consideration; OL = Overall Layout; IP = Inpatient; D&T = Diagnostic & Treatment; Rx = Pharmacy; ED = Emergency Department; HIM = Med. Records/Health Information Mgmt; OR = Operating; SEC = Seclusion

FGI

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Building category

613 Avoid/eliminate dead-end parking areas and areas of concealment. GEN Site Optimization

614 Locate security officer posts and/or police officer workstations, when accommodated in a building, to maximize visibility at public entrances, waiting areas, registration and information areas.

GEN

Building Layout

GEN

Building Layout

615 Limit and control points of entry into and exit from the building, while ensuring vehicular and pedestrian safety.

616 Put in place penetration-resistant protective measures that extend from solid floor to solid ceiling or roof in the building envelope for highly security-sensitive areas.

Building GEN Envelope/Structu re

617 Implement segregation of authorized and unauthorized visitors in security-sensitive patient areas.

Copyright 2012-2015 The Center for Health Design. All Rights Reserved.

GEN

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Building Layout

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Cost Magnitude Select Select Select Select Select

Select

Select

Your Priority Select Select

Public areas often have least restrictions for people to access while access-restricted areas only open to authorized individuals. Separating general public areas, waiting areas, including patient and visitor paths from access-restricted areas, can help to contain and manage risk of unauthorized entrance into the restricted areas.

Select

Select

Select Select Select

Why should this be considered? (Rationale) (This cell hyperlinks to references)

Select

Generic Risk Estimate Highest Highest

Copyright 2012-2015 The Center for Health Design. All Rights Reserved.

Select

623 Maximize line of sight and visibility in areas with aggressive and disruptive patients.

Safe Design Roadmap

Select

622 Provide adequate and unobstructed electronic surveillance of aggressive and disruptive patient areas, while at the same time minimizing compromise of patient and staff privacy.

Select

621 Put in place intrusion detection systems in high-risk areas of the hospital that are not staffed 24/7.

Highest

620 Position workstations in security-sensitive areas to provide staff direct access to an exit (safe drop-back zone), and equip them with strategically located duress alarms.

MedHigh

619 Design the workstations in patient care areas where there is a high risk of physical violence to staff to prevent unwanted access. (The degree of enclosure and protective material used should depend on the assessed vulnerability and patient population.)

Highest

618 Design the layout to ensure that patient and visitor paths or “screened public” paths do not pass through designated staff-only security zones.

Highest

Sort #

What is being discussed? (Design Consideration)

Your Risk Estimate

Project Data

Risk Data: Security

A Safety Risk Assessment for Healthcare Facility Environments

Staff can be vulnerable to attacks or assaults from patients (Blando et al., 2012). To protect the staff, workstations need to be designed after assessing the area specific risk/vulnerability. For example, the potential risk of physical violence to staff may be relatively higher in ED waiting areas, or behavioral health units. Protective measures for workstations may help deter potential violence or unwanted access. Staff can be vulnerable to attacks or assaults from patients (Blando et al., 2012). To protect the staff, workstations need to be designed after assessing the area specific risk/vulnerability. For example, the potential risk of physical violence to staff may be relatively higher in ED waiting areas, or behavioral health units. Safe exits and alarms may help protect staff in case of attacks or assaults. In a hospital, some high risk areas are not staffed 24/7. Electrical intrusion detection systems can help to detect security risks, as well as notify security staff to enable prompt action on any breaches identified. The ability to monitor areas associated with aggressive and disruptive patients can help mitigate security risks, as well as enable prompt action on any breaches identified. These patients may need to be monitored by clinical, as well as security, staff. At the same time it is important to ensure that patient privacy is protected since electronic surveillance mechanisms are often invisible to the patients. The ability of security staff to directly monitor areas with aggressive and disruptive patients can help to mitigate security risks, as well as enable prompt action on any breaches identified.

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Risk Data: Security

A Safety Risk Assessment for Healthcare Facility Environments Glossary/Definitions

The Risk Component Links

What is being discussed? (Design Consideration)

How is this done? Explanations/Clarifications (How Accomplished, Reasons Against)

618 Design the layout to ensure that patient and visitor paths or “screened public” paths do not pass through designated staff-only security zones.

619 Design the workstations in patient care areas where there is a high risk of physical violence to staff to prevent unwanted access. (The degree of enclosure and protective material used should depend on the assessed vulnerability and patient population.) 620 Position workstations in security-sensitive areas to provide staff direct access to an exit (safe drop-back zone), and equip them with strategically located duress alarms. 621 Put in place intrusion detection systems in high-risk areas of the hospital that are not staffed 24/7. 622 Provide adequate and unobstructed electronic surveillance of aggressive and disruptive patient areas, while at the same time minimizing compromise of patient and staff privacy. 623 Maximize line of sight and visibility in areas with aggressive and disruptive patients.

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B = Body (required); A = Appendix (suggested); N/I or blank = not included

Location

Sort #

Location Key: GEN = General Consideration; OL = Overall Layout; IP = Inpatient; D&T = Diagnostic & Treatment; Rx = Pharmacy; ED = Emergency Department; HIM = Med. Records/Health Information Mgmt; OR = Operating; SEC = Seclusion

FGI

118

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Building category

GEN

Unit Layout

GEN

Unit Layout

GEN

Unit Layout

GEN

Technology Integration

GEN

Unit Layout

GEN

Unit Layout

A

119

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Copyright 2012-2015 The Center for Health Design. All Rights Reserved.

Select

Select

Select

Select

Cost Magnitude

Safe Design Roadmap

Select

Your Priority Select Select Select

Select

Select Select Select

Generic Risk Estimate Med-Low Highest

Select

628 Consider the protection of HVAC systems against chemical, biological and radiological attacks. (e.g., protection of outside air intakes, location of return air grilles and types of filtration).

Select

627 Use physical separation and other security measures to prevent unauthorized access to areas in healthcare facilities containing hazardous materials.

Select

626 Identify unique security risks presented by highly hazardous materials including but not limited to biological, chemical and radioactive materials.

Highest

625 Evaluate electronic security issues, and the safety and security of information systems, during the design of the physical environment.

Highest

624 Ensure that wayfinding and other signs do not compromise direct visibility (sightlines) and electronic surveillance systems in place.

Med-High

Sort #

What is being discussed? (Design Consideration)

Your Risk Estimate

Project Data

Risk Data: Security

A Safety Risk Assessment for Healthcare Facility Environments

Why should this be considered? (Rationale) (This cell hyperlinks to references) Often surveillance systems may be compromised due to wayfinding or other signage which is placed without consideration of how it might affect the direct visual surveillance or electronic surveillance system in place. For example signs may block the view of CCTV cameras, or the line of sight from a staffed area to a security sensitive area. The physical environment provides the structure to support electronic and information systems- relevant design elements include power outlets, cabling, physical location and placement of systems, and so on which may impact the security of electronic / information systems (Yow, 2012). There are many highly hazardous materials including, but not limited to, biological, chemical, and radioactive materials- in healthcare settings. These materials require the identification and implementation of specific security measures (including physical environmental measures), in keeping with the nature of the material and associated regulations. Highly hazardous materials including—but not limited to—biological, chemical, and radioactive materials- require the implementation of specific security measures, in keeping with the nature of the material and associated regulations. To prevent harm due to hazardous materials, it is essential to clearly identify the areas containing hazardous materials as well as securely collect and store them. Chemical and biological hazards are a key concern for the facility infrastructure and can compromise mechanical and HVAC systems. Protecting the HVAC systems from such hazards protects all the people in the HCF as well.

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Risk Data: Security

A Safety Risk Assessment for Healthcare Facility Environments Glossary/Definitions

The Risk Component Links

What is being discussed? (Design Consideration)

How is this done? Explanations/Clarifications (How Accomplished, Reasons Against)

624 Ensure that wayfinding and other signs do not compromise direct visibility (sightlines) and electronic surveillance systems in place.

B = Body (required); A = Appendix (suggested); N/I or blank = not included

Location

Sort #

Location Key: GEN = General Consideration; OL = Overall Layout; IP = Inpatient; D&T = Diagnostic & Treatment; Rx = Pharmacy; ED = Emergency Department; HIM = Med. Records/Health Information Mgmt; OR = Operating; SEC = Seclusion

FGI

120

600-Security Design

Building category

GEN

Interior Design/Finishes

GEN

Technology Integration

A

626 Identify unique security risks presented by highly hazardous materials including but not limited to biological, chemical and radioactive materials.

GEN

Unit Layout

A

627 Use physical separation and other security measures to prevent unauthorized access to areas in healthcare facilities containing hazardous materials.

GEN

Unit Layout

A

GEN

Mechanical (HVAC)/Electrical

A

625 Evaluate electronic security issues, and the safety and security of information systems, during the design of the physical environment.

628 Consider the protection of HVAC systems against chemical, biological and radiological attacks. (e.g., protection of outside air intakes, location of return air grilles and types of filtration).

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Select Select

Cost Magnitude

Select Select

Your Priority

Select Select

Generic Risk Estimate

Why should this be considered? (Rationale) (This cell hyperlinks to references) Physical separation may address security risks related to pharmacy operations include threat of burglary, and threat to personal safety of staff, in addition to threat to property. Additionally, creating secure and uninterrupted spaces for medication administration has been linked to reduction in errors. Securing the pharmacy area with physical separation needs to be balanced with making the pharmacy accessible as needed (without compromising security). Research suggests that a closed off, uninterrupted area for medication dispensing can aid in reducing medication errors. Additionally it can ensure the security of pharmaceutical supplies.

Copyright 2012-2015 The Center for Health Design. All Rights Reserved.

Select

Select

Providing secured storage may help to prevent unauthorized access to certain hazardous materials and controlled drugs and ensure the security of pharmaceutical supplies. Select

631 Provide secured storage cabinets, shelves and/or separate rooms or closets for the following as required: a. Storage for volatile fluids and alcohol in accordance with applicable fire safety codes for the substances involved b. Secured lockable storage for narcotics and controlled drugs

Highest

630 Provide the following in the medication dispensing areas: a. A secured room or area for receiving, breakout and inventory control of materials used in the pharmacy b. A secured area for temporary storage, exchange and restocking of carts c. Security provisions for drugs and personnel in the dispensing counter area

Safe Design Roadmap

Highest

629 Create a secure physical separation between pharmacy operations and the public using penetration-resistant protective measures that extend from solid floor to solid ceiling or roof, while maintaining clinical accessibility.

Med-High

Sort #

What is being discussed? (Design Consideration)

Your Risk Estimate

Project Data

Risk Data: Security

A Safety Risk Assessment for Healthcare Facility Environments

V1.2 October2015

Risk Data: Security

A Safety Risk Assessment for Healthcare Facility Environments Glossary/Definitions

The Risk Component Links

What is being discussed? (Design Consideration)

How is this done? Explanations/Clarifications (How Accomplished, Reasons Against)

629 Create a secure physical separation between pharmacy operations and the public using penetration-resistant protective measures that extend from solid floor to solid ceiling or roof, while maintaining clinical accessibility.

B = Body (required); A = Appendix (suggested); N/I or blank = not included

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Location Key: GEN = General Consideration; OL = Overall Layout; IP = Inpatient; D&T = Diagnostic & Treatment; Rx = Pharmacy; ED = Emergency Department; HIM = Med. Records/Health Information Mgmt; OR = Operating; SEC = Seclusion

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630 Provide the following in the medication dispensing areas: a. A secured room or area for receiving, breakout and inventory control of materials used in the pharmacy b. A secured area for temporary storage, exchange and restocking of carts c. Security provisions for drugs and personnel in the dispensing counter area

Rx

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B

631 Provide secured storage cabinets, shelves and/or separate rooms or closets for the following as required: a. Storage for volatile fluids and alcohol in accordance with applicable fire safety codes for the substances involved b. Secured lockable storage for narcotics and controlled drugs

Rx

Unit Layout

B

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Security of medical records relates to patient right to information and the safeguarding of patient medical information. It is also at the core of clinical operations at the hospital. One effective methods of preventing breaches of medical records is providing lockable secure storage spaces for medical records.

Select

Select

Select

Highest

Security of pharmaceutical supplies can directly impact security of staff and property, and it indirectly impacts safety of patients. Potential routes for accessing pharmaceutical supplies should be blocked to prevent unauthorized access.

Security of medical records relates to patient right to information and the safeguarding of patient medical information. It is also at the core of clinical operations at the hospital. One effective method of preventing breaches of medical records is physically separating medical records from treatment and public areas.

635 Ensure that ED cannot be accessed by unauthorized visitors and personnel at all times.

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Why should this be considered? (Rationale) (This cell hyperlinks to references)

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Select

Cost Magnitude

Safe Design Roadmap

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Your Priority Select

Generic Risk Estimate Med-Low

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634 Secure medical records in all media (paper and electronic), and protect them from loss or damage as required by the functional program. (This is also related to category of unit layout, if paper medical records are used.)

Select

633 Locate medical records away from treatment and public areas, and/or restrict medical records to areas with staff access only.

Med-Low

632 Prevent access above suspended ceilings through air ducts, cable or utility infrastructure, roof hatches, skylights, unprotected external windows, doors and dumbwaiters. (This consideration is also relevant under the following category: mechanical(HVAC)/electrical.)

Med-Low

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Your Risk Estimate

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Risk Data: Security

A Safety Risk Assessment for Healthcare Facility Environments

EDs are vulnerable to internal as well as external threats that need to be addressed together. ED incidents, including incidences of violence and aggression, are typically recorded by the healthcare organizations and can be used for benchmarking. There is a growing body of research around reducing violence in EDs. However, within the purview of security the concern is to mitigate, and contain, the security risk. As with other security sensitive areas, controlling access is the key.

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What is being discussed? (Design Consideration)

How is this done? Explanations/Clarifications (How Accomplished, Reasons Against)

632 Prevent access above suspended ceilings through air ducts, cable or utility infrastructure, roof hatches, skylights, unprotected external windows, doors and dumbwaiters. (This consideration is also relevant under the following category: mechanical(HVAC)/electrical.) 633 Locate medical records away from treatment and public areas, and/or restrict medical records to areas with staff access only. 634 Secure medical records in all media (paper and electronic), and protect them from loss or damage as required by the functional program. (This is also related to category of unit layout, if paper medical records are used.)

B = Body (required); A = Appendix (suggested); N/I or blank = not included

Location

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Location Key: GEN = General Consideration; OL = Overall Layout; IP = Inpatient; D&T = Diagnostic & Treatment; Rx = Pharmacy; ED = Emergency Department; HIM = Med. Records/Health Information Mgmt; OR = Operating; SEC = Seclusion

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B

HIM

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B

ED

Unit Layout

B

635 Ensure that ED cannot be accessed by unauthorized visitors and personnel at all times.

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Cost Magnitude Select

Your Priority Select

Select

Safe Design Roadmap

Why should this be considered? (Rationale) (This cell hyperlinks to references) Controlled access and increased visual surveillance can help deter and detect attempts of unauthorized entry and other security breaches, and improve response in the case of a security breach.

Select

Select

Disruptive/aggressive patients should be properly monitored and controlled to protect staff and other patients from potential physical and psychological threats and to improve response in the case of a security breach. Select

Generic Risk Estimate Highest

636 Locate ED reception or triage areas to provide unobstructed uninterrupted staff observation of public access points to the department, the public waiting area, including patients who are waiting for treatment, and the treatment area. 637 Designate access-controlled and monitored (video and audio surveillance) patient/observation rooms for disruptive/aggressive patients or patients at high risk of elopement.

Highest

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What is being discussed? (Design Consideration)

Your Risk Estimate

Project Data

Risk Data: Security

A Safety Risk Assessment for Healthcare Facility Environments

Copyright 2012-2015 The Center for Health Design. All Rights Reserved.

Select

Select

Select

638 Include access to panic buttons for security emergencies in high-risk areas (e.g., triage).

Highest

(This is also related to the section on behavioral health and psychiatric injury.) Communication systems in easy-to-access locations would facilitate the coordination between security, clinicians, and other staff, and speed up proper reactions in case of emergency situations.

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What is being discussed? (Design Consideration)

How is this done? Explanations/Clarifications (How Accomplished, Reasons Against)

636 Locate ED reception or triage areas to provide unobstructed uninterrupted staff observation of public access points to the department, the public waiting area, including patients who are waiting for treatment, and the treatment area. 637 Designate access-controlled and monitored (video and audio surveillance) patient/observation rooms for disruptive/aggressive patients or patients at high risk of elopement.

B = Body (required); A = Appendix (suggested); N/I or blank = not included

Location

Sort #

Location Key: GEN = General Consideration; OL = Overall Layout; IP = Inpatient; D&T = Diagnostic & Treatment; Rx = Pharmacy; ED = Emergency Department; HIM = Med. Records/Health Information Mgmt; OR = Operating; SEC = Seclusion

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ED

Unit Layout

ED

Unit Layout

ED

Technology Integration

(This is also related to the section on behavioral health and psychiatric injury.) 638 Include access to panic buttons for security emergencies in high-risk areas (e.g., triage).

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Term

Definition

Medication Safety Zone (MSZ)

A MSZ is defined in the literature as a critical area where medications are prescribed, orders are entered into a computer or transcribed onto paper documents, and where medications are prepared, dispensed or administered. Examples include work surfaces of medication cart, nursing units, any location where prescribing decisions are made, work surface of an automated medication dispensing device, pharmacy, and patient bedside.

Project Phases and Definitions

Figure 2: Traditional Design Process Workflow (Taylor, 2013)

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Design Phase Term

Definition

Strategic Planning

A strategic plan helps hospitals and systems adapt to market conditions and changes in healthcare environments. The CEO along with the Board of Directors has a leadership role in creating the strategic plan, which includes the development of the organization’s mission, vision, strategy and values statements; defining the critical strategic issues, making the transition from planning to implementation, communicating and rolling out the plan’s findings and recommendations, and conducting an annual strategic plan update as part of an ongoing management process. (Synthesized from Healthcare Strategic Planning, Second Edition, Alan M. Zuckerman, FACHE, FAAHC) Healthcare master planning is a guide for decision-making prepared by identifying capital improvement needs that accommodate future growth of a facility that includes potential operational and infrastructure needs for delivering quality healthcare. It is a multi-phase process undertaken by healthcare planners, architects and other industry consultants to consider long-term strategies that consider logistical and financial feasibility, as well as flexibility to accommodate future change. It considers site/campus planning, zoning, existing building analysis, departmental analysis, projected workloads and demands, gross area sizes, and options for potential configurations. (Synthesized from AIA AAH Healthcare 101: Master Planning.) Operational planning reflects current and future business and clinical processes, organizational structure and technology after taking into account existing investments, process priorities opportunities for improvement and change management implications. The operational plan establishes the operational link to strategic objectives by providing a common view and vocabulary of all relevant processes; aligns key metrics that assist the organization in documenting its current state (and track progress over time); ensures agreement between and buy-in from physicians, administration and staff who are accountable for successful execution; and establishes an appropriate organizational/governance model with the authority to implement and sustain the required changes through continual process assessment and design of workflows.

Facility Master Planning

Process and Operational Planning

Programming

Architectural programming is the research and decision-making process that identifies the issues and problems that a design process must address and resolve. The result is interconnected on both a pragmatic and inspirational level that defines the scope of work to be designed by identifying existing condition evaluation; space requirements; overall building use requirements; zoning and community issues; the relationship between building components; measures for growth and change; and code summaries and regulatory requirements. (Whole Building Design Guide (WBDG)/American Institute for Architects (AIA) Handbook of Professional Practice.) A functional program is required by the Facility Guideline Institute (FGI) Guidelines for the Design and Construction of Healthcare Facilities and is described through 1) the purpose of the project (required services; environment of care components; delivery of care models; facility and service users; systems design; layout and operational planning; physical environment; and design process and implementation), and 2) the functional requirements (demand; space relationships; user needs; operational needs; space and equipment needs; and short- and long-term planning considerations. (FGI Guidelines, 2010).

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Design

Design is considered in two phase: schematic design (SD) and design development (DD). During SD, an architect and client establish the scope, conceptual design and scale and relationship of the project components to establish a clearly defined and feasible concept with a reasonable basis for estimating project cost. Design development (DD) uses the documents from the schematic phase and provides additional refinement and coordination. This phase lays out mechanical, electrical, plumbing, structural and architectural details. This phase results in drawings that often specify design elements such as material types; location of windows and doors; interior elevations; wall sections; reflected ceiling plans; pertinent details and; more detailed specifications. Cost estimates are updated. (Summarized from AIA Handbook of Professional Practice.)

Construction Documents

When finalizing construction documents (CDs), final materials and systems are selected, while details and dimensions are finalized. (AIA Handbook of Professional Practice.)

Construction

Several delivery methods are used for construction. In design-bid-build, a project is designed and documented with drawings and specifications, competitively bid to multiple general contractors, and then built by the general contractor, guided by a contract with the owner of the project. Design-build uses a single entity that holds a single contract with an owner for both the design and construction of a project. Construction management is a method that involves the coordination and management of the entire process via a single entity—from site survey through occupation. It encompasses the evaluation, selection and management of all contractors, as well as the administration of the project budget relative to the implementation of design (WBDG). Construction may include phasing and temporary structures to ensure the safe and continuous operation of an existing facility. Requirements surrounding infection control and risk mitigation are required in many areas. The American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE) define commissioning as "a qualityoriented process for achieving, verifying, and documenting that the performance of facilities, systems, and assemblies meets defined objectives and criteria." It is typically used for dynamic systems such as HVAC (heating, ventilation and air conditioning) and certain types of equipment. It is conducted prior to turning over the facility to the owner. The punch list is typically completed by the design team with a walk-through inspection at substantial completion. The punch list identifies incomplete or unsatisfactory work, as defined in the contract documents. The items are usually static in nature, such as drywall or paint irregularities, carpet stains, broken hardware, etc.) Many states require an inspection prior to issuing a Certificate of Occupancy (CO) or Temporary Certificate of Occupancy (TCO). After issuance, the owner takes control of the building and can begin moving furniture and equipment. In larger healthcare facilities, staff and clinicians use simulations, scenarios and walk-throughs to ensure they are familiar with the new environment prior to full operation of the building, licensing, certification and accepting or moving patients.

Commissioning and Punch List

Occupancy

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Beggs, C. B., Kerr, K. G., Noakes, C. J., Hathway, E. A., & Sleigh, P. A. (2008). The ventilation of multiple-bed hospital wards: review and analysis. Am J Infect Control , 36 (4), 250–9. Bell, J. L., Collins, J. W., Dalsey, E., & Sublet, V. (2010). (DHHS (NIOSH) No. 2011–123) (pp. 1–56). Washington DC: CDC/DHHS (NIOSH). Retrieved from http://www.cdc.gov/niosh/docs/2011-123/ Blando, J. D., McGreevy, K., O’Hagan, E., Worthington, K., Valiante, D., Nocera, M., … Peek-Asa, C. (2012). Emergency department security programs, community crime, and employee assaults. The Journal of Emergency Medicine , 42 (3), 329–338. doi:10.1016/j.jemermed.2008.06.026 Bowers, L., Banda, T., & Nijman, H. (2010). Suicide inside: a systematic review of inpatient suicides. J Nerv Ment Dis , 198 (5), 315–28. doi:10.1097/NMD.0b013e3181da47e2 Brogmus, G., Leone, W., Butler, L., & Hernandez, E. (2007). Best practices in OR suite layout and equipment choices to reduce slips, trips, and falls. Association of Perioperative Registered Nurses , 86 (3), 384–398. Buchanan, T. L., Barker, K. N., Gibson, J. T., Jiang, B. C., & Pearson, R. E. (1991). Illumination and errors in dispensing. American Journal of Hospital Pharmacy , 48 (10), 2137–45. Calkins, M. P., Biddle, S., & Biesan, O. (2012). (Research) (pp. 1–100). Concord, CA: The Center for Health Design. Retrieved from https://www.healthdesign.org/chd/knowledge-repository/contribution-designed-environment-fall-risk-hospitals Capezuti, E., Maislin, G., Strumpf, N., & Evans, L. K. (2002). Side rail use and bed-related fall outcomes among nursing home residents. Journal of the American Geriatrics Society , 50 (1), 90–6. Capezuti, E., Strumpf, N. E., Evans, L. K., Grisso, J. A., & Maislin, G. (1998). The Relationship Between Physical Restraint Removal and Falls and Injuries Among Nursing Home Residents. , 53A (1), M47–M52. doi:10.1093/gerona/53A.1.M47 Cardell, R., Bratcher, K. S., & Quinnett, P. (2009). Revisiting “suicide proofing” an inpatient unit through environmental safeguards: a review. Perspect Psychiatr Care , 45 (1), 36–44. doi:10.1111/j.1744-6163.2009.00198.x Carroll, D., Pappola, L., & McNicoll, L. (2009). Fall Prevention Interventions In Acute Care Settings: The Rhode Island Hospital Experience. Medicine and Health Rhode Island , 92 (8), 280–2. Chang, V. T., & Nelson, K. (2000). The role of physical proximity in nosocomial diarrhea. Clinical Infectious Diseases , 31 (3), 717–22. Chaudhury, H., Mahmood, A., & Valente, M. (2009). The Effect of Environmental Design on Reducing Nursing Errors and Increasing Efficiency in Acute Care Settings A Review and Analysis of the Literature. Environment and Behavior , 41 (6), 755–786. doi:10.1177/0013916508330392 Chen, K.-H., Chen, L.-R., & Su, S. (2010). Applying root cause analysis to improve patient safety: decreasing falls in postpartum women. Quality and Safety in Health Care , 19 (2), 138–143. doi:10.1136/qshc.2008.028787 Choi, Y. S., Noblis, & Georgia Tech. (2011). (Military Health System). Noblis/Gerorgia Tech, TRICARE. Retrieved from https://facilities.health.mil/Repository/getFile/35 Coiera, E. (2012). The science of interruption. BMJ Quality & Safety , bmjqs–2012–000783. doi:10.1136/bmjqs-2012-000783

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Curran, E. T., Hamilton, K., Monaghan, A., McGinlay, M., & Thakker, B. (2006). Use of a temporary cohort ward as part of an intervention to reduce the incidence of meticillin-resistant Staphylococcus aureus in a vascular surgery ward. Journal of Hospital Infection , 63 (4), 374–379. Dobrohotoff, J. T., & Llewellyn-Jones, R. H. (2011). Psychogeriatric inpatient unit design: a literature review. Int Psychogeriatr , 23 (2), 174–89. doi:10.1017/S1041610210002097 Dykes, P., & Carroll, D. (2010). Fall prevention in acute care hospitals: A randomized trial. , 304 (17), 1912–1918. doi:10.1001/jama.2010.1567 ECRI Institute, & The Institute for Safe Medication Practices. (2007). Diligence and Design in Behavioral Health Impact Patient Safety. PA Patient Safety Advisory , 4 (3), 78–82. Fakhry, M., Hanna, G. B., Anderson, O., Holmes, A., & Nathwani, D. (2012). Effectiveness of an audible reminder on hand hygiene adherence. Am J Infect Control , 40 (4), 320–3. Fink, N., Pak, R., & Battisto, D. (2010). Developing a usability evaluation tool to assess the patient room bathroom. HERD , 3 (3), 22–41. Flynn, E. A., Barker, K. N., Gibson, J. T., Pearson, R. E., Berger, B. A., & Smith, L. A. (1999). Impact of interruptions and distractions on dispensing errors in an ambulatory care pharmacy. American Journal of Health Systems Pharmacy , 56 (13), 1319–25. Flynn, E., Dorris, N., Holman, G., Carnahan, B., & Barker, K. (2002). Medication Dispensing Errors in Community Pharmacies: A Nationwide Study. In HUMAN . Flynn, L., Liang, Y., Dickson, G. L., Xie, M., & Suh, D.-C. (2012). Nurses’ practice environments, error interception practices, and inpatient medication errors. , 44 (2), 180–186. Fonda, D., Cook, J., Sandler, V., & Bailey, M. (2006). Sustained reduction in serious fall-related injuries in older people in hospital. The Medical Journal of Australia , 184 (8), 379–382. Fraser, V. J., Johnson, K., Primack, J., Jones, M., Medoff, G., & Dunagan, W. C. (1993). Evaluation of rooms with negative pressure ventilation used for respiratory isolation in seven midwestern hospitals. , Galbraith, J., Butler, J., Memon, A., Dolan, M., & Harty, J. (2011). Cost Analysis of a Falls-prevention Program in an Orthopaedic Setting. Clinical Orthopaedics and Related Research® , 469 (12), 3462–3468. doi:10.1007/s11999-011-1932-9 Goh, S. E., Salmons, P. H., & Whittington, R. M. (1989). Hospital suicides: are there preventable factors? Profile of the psychiatric hospital suicide. Br J Psychiatry , 154 , 247–9.

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Gournay, K., & Bowers, L. (2000). Suicide and self-harm in in-patient psychiatric units: a study of nursing issues in 31 cases. Journal of Advanced Nursing , 32 (1), 124–131. doi:10.1046/j.1365-2648.2000.01453.x Grissinger, M. (2012). Physical Environments That Promote Safe Medication Use. Pharmacy and Therapeutics , 37 (7), 377–378. Gulwadi, G. B. P., & Calkins, M. P. P. (2008). . Concord. Retrieved from http://www.healthdesign.org/research/reports/patient_falls.php Gunnell, D., Bennewith, O., Hawton, K., Simkin, S., & Kapur, N. (2005). The epidemiology and prevention of suicide by hanging: a systematic review. Int J Epidemiol , 34 (2), 433–42. doi:10.1093/ije/dyh398 Gurascio-Howard, L., & Malloch, K. (2007). Centralized and Decentralized Nurse Station Design: An Examination of Caregiver Communication, Work Activities, and Technology. HERD-HEALTH ENVIRONMENTS RESEARCH & DESIGN JOURNAL , 1 (1), 44–57. Gustafson, T. L., Lavely, G. B., Brawner, J., E. R., Hutcheson, J., R. H., Wright, P. F., & Schaffner, W. (1982). An outbreak of airborne nosocomial varicella. Pediatrics , 70 (4), 550–6. Gutierrez, F., & Smith, K. (2008). Reducing Falls in a Definitive Observation Unit: An Evidence-Based Practice Institute Consortium Project. Critical Care Nursing Quarterly , 31 (2), 127–139 10.1097/01.CNQ.0000314473.72001.b4. Hanger, H. C., Ball, M. C., & Wood, L. A. (1999). An analysis of falls in the hospital: Can we do without bedrails? Journal of the American Geriatrics Society , 47 (5), 529–31. Hardin, S. R., Dienemann, J., Rudisill, P., & Mills, K. K. (2013). Inpatient fall prevention: use of in-room Webcams. Journal of Patient Safety , 9 (1), 29–35. doi:10.1097/PTS.0b013e3182753e4f Harris, D., Pacheco, A., & Lindner, A. S. (2010). Detecting potential pathogens on pospital surfaces: An assessment of carpet tile flooring in the hospital patient environment. Indoor and Built Environment , 19 (2), 239–249. Harrison, W. A., Griffith, C. J., Ayers, T., & Michaels, B. (2003). Bacterial transfer and cross-contamination potential associated with paper-towel dispensing. American Journal of Infection Control , 31 (7), 387–391. doi:10.1067/mic.2003.81 Harwood, R. H., & Ebrahim, S. (1992). Long-term institutional residents: does the environment affect outcomes? J R Coll Physicians Lond , 26 (2), 134–8. Hathaway, J., Walsh, J., Lacey, C., & Saenger, H. (2001). INSIGHTS OBTAINED FROM AN EVALUATION OF A FALLS PREVENTION PROGRAM SET IN A RURAL HOSPITAL. Australian Journal of Rural Health , 9 (4), 172–177. doi:10.1046/j.1038-5282.2001.00365.x Healey, F. (1994). Does flooring type affect risk of injury in older in-patients? Nurs Times , 90 (27), 40–1. Health Guidelines Revisions Committee Specialty Subcommittee on Patient Movement. (2010). (White Paper) (p. 149). Dallas, TX: Facility Guidelines Institute. Retrieved from www.fgiguidelines.org/pdfs/FGI_PHAMA_whitepaper_042810.pdf Hendrich, A., Fay, J., & Sorrells, A. (2004). Effects of acuity-adaptable rooms on flow of patients and delivery of care. American Journal of Critical Care , 13 (1), 35–45.

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