Download Environmental Risk Assessment – Addiction

Corporate Policy & Procedures
Environmental Risk
Assessment
– Addiction & Mental Health
Approved by:
Senior Operating Officer, Mental Health & Seniors Care
Edmonton
Purpose
Policy
Statement
Manual
Number: VII-B-220
Date Approved
December 1, 2016
Date Effective
December 9, 2016
Next Review (3 years from Effective
Date)
December 2019
• To facilitate a safe environment for all Addiction & Mental Health patients, staff,
physicians, and visitors.
• To guide staff when reporting an environmental risk.
Staff shall take action to remove or eliminate identified environmental hazards that
patients may use to engage in self-injurious behaviour and/or harm to others.
Ongoing, or day to day assessments shall occur as the need arises. For example, when
a renovation is taking place on the unit and contractor workers and their equipment are
accessible to patients. Written environmental risk assessments are completed on an
annual basis and are submitted to the Senior Operating Officer, Mental Health & Seniors
Care Edmonton.
Applicability
This policy and procedure applies to all Covenant Health acute inpatient mental health
programs, and the staff and physicians working within those programs.
Responsibility All staff share the responsibility to identify and take timely, appropriate action to remedy
identified hazards.
The Program Manager is responsible to ensure a written environmental risk assessment
is completed on an annual basis and submitted to the Senior Operating Officer, Mental
Health & Seniors Care Edmonton.
Principles
A systematic tool for conducting risk assessments should be used to identify
environmental safety concerns on mental health units. For this purpose the AHS Modified
Mental Health Environment of Care Checklist shall be completed at least every two years
Staff who work on an inpatient mental health unit shall be vigilant to:
a)
Identify environmental items that may be used by inpatients to engage in
self-injurious behaviour and/or harm to others;
b)
Report identified risks to their manager/supervisor; and
c)
Work to eliminate or minimize risks to provide a safer environment.
Environmental Risk Assessment – Mental Health Program
Procedure
Date Effective:
Dec. 9, 2016
Policy No.
VII-B-220
Page 2 of 2
1.
All staff shall take whatever steps are appropriate within their position to mitigate any
immediate risk. Staff will report hazards to the immediate supervisor.
2.
Lock all rooms that are not in use, including but not limited to unobserved areas,
interview, conference and seclusion rooms, etc.
3.
Prior to commencement of structural modifications or renovations, review potential
environmental hazards (eg. any item that can be used as a ligature point - fixtures
and fittings in bathrooms, shelves, fire sprinklers, towel racks, shower heads, ceiling
lights, etc.) Design shall attempt to comply with the Modified Mental Health
Environment of Care Checklist.
4.
Ensure that building/plumbing fixtures or fittings that are being installed cannot
support the weight of a body. Work/design shall attempt to comply with the Modified
Mental Health Environment of Care Checklist.
5.
Cleaning or contracted staff present on the unit, will manage environmental risks
(eg. hazards from chemicals, extension cords, etc.) as appropriate. Unit staff will
direct cleaning or contracted staff as required in response to patient acuity and
changes in unit dynamics.
Related
Documents
Mental Health Environment of Care Checklist
References
Mental Health Environment of Care Checklist, VHA National Center for Patient Safety,
Department of Veterans Affairs. Version 09-22-2011
Revisions
October 15, 2012