1
Cover
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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Here
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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
Copyright 2012-2015 The Center for Health Design. All Rights Reserved.
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Volunteers
A Safety Risk Assessment for Healthcare Facility Environments
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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
Copyright 2012-2015 The Center for Health Design. All Rights Reserved.
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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
Copyright 2012-2015 The Center for Health Design. All Rights Reserved.
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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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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
Copyright 2012-2015 The Center for Health Design. All Rights Reserved.
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A Safety Risk Assessment for Healthcare Facility Environments
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A Safety Risk Assessment for Healthcare Facility Environments
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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
Copyright 2012-2015 The Center for Health Design. All Rights Reserved.
Medication
Safety
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Behavioral
Health
Security
7
Safe Design Roadmap Intro
A Safety Risk Assessment for Healthcare Facility Environments
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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)
Copyright 2012-2015 The Center for Health Design. All Rights Reserved.
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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
Home
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.
Copyright 2012-2015 The Center for Health Design. All Rights Reserved.
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#DIV/0!
1
2
3
4
5
6
7
8
9
10
=
Safe Design Score (average rating)
10
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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16
17
18
19
20
21
22
23
24
11
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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12
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
Copyright 2012-2015 The Center for Health Design. All Rights Reserved.
V1.2 October2015
Areas where medication preparation, processing and
distribution occur?
Complete Medication Safety Assessment
Areas where a patient or family member has access?
Complete Falls Assessment
13
RiskComponentLinks
Risk Components
Home
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 <1066> Physical
Environments (outside link)
IAHSS Security Guidelines information
(outside link)
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V1.2 October2015
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Infection Control Risk Data
Design Considerations:
Infection Control
Home
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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V1.2 October2015
Almost Certain
15
Infection Control Risk Data
Home
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)
V1.2 October2015
Title/Role
Data Source
16
ICRA Matrix
Home
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.
Copyright 2012-2015 The Center for Health Design. All Rights Reserved.
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17
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 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
Copyright 2012-2015 The Center for Health Design. All Rights Reserved.
Type C
II
III
III/IV
III/IV
V1.2 October2015
Type D
III/IV
IV
IV
IV
Glossary/Definitions
18
ICRA Matrix
Home
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?
Copyright 2012-2015 The Center for Health Design. All Rights Reserved.
V1.2 October2015
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.
Copyright 2012-2015 The Center for Health Design. All Rights Reserved.
V1.2 October2015
Glossary/Definitions
21
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).
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)
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.
Copyright 2012-2015 The Center for Health Design. All Rights Reserved.
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).
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)
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
Location
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.
Copyright 2012-2015 The Center for Health Design. All Rights Reserved.
V1.2 October2015
25
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).
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)
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.
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)
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.
Copyright 2012-2015 The Center for Health Design. All Rights Reserved.
V1.2 October2015
29
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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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)
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)
Copyright 2012-2015 The Center for Health Design. All Rights Reserved.
V1.2 October2015
31
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.
Copyright 2012-2015 The Center for Health Design. All Rights Reserved.
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)
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.
Copyright 2012-2015 The Center for Health Design. All Rights Reserved.
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
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.
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: 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.
Copyright 2012-2015 The Center for Health Design. All Rights Reserved.
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.
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)
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
V1.2 October2015
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
Copyright 2012-2015 The Center for Health Design. All Rights Reserved.
V1.2 October2015
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)
Copyright 2012-2015 The Center for Health Design. All Rights Reserved.
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)
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)
Copyright 2012-2015 The Center for Health Design. All Rights Reserved.
V1.2 October2015
41
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
Copyright 2012-2015 The Center for Health Design. All Rights Reserved.
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
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.
Copyright 2012-2015 The Center for Health Design. All Rights Reserved.
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.
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)
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.)
Copyright 2012-2015 The Center for Health Design. All Rights Reserved.
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).
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)
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.)
Copyright 2012-2015 The Center for Health Design. All Rights Reserved.
V1.2 October2015
47
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 <1066> 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.
Copyright 2012-2015 The Center for Health Design. All Rights Reserved.
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)
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.
Copyright 2012-2015 The Center for Health Design. All Rights Reserved.
V1.2 October2015
49
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.
Copyright 2012-2015 The Center for Health Design. All Rights Reserved.
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)
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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V1.2 October2015
53
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
Copyright 2012-2015 The Center for Health Design. All Rights Reserved.
V1.2 October2015
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)
V1.2 October2015
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) .
V1.2 October2015
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300-Falls Design
Risk Data: Falls
A Safety Risk Assessment for Healthcare Facility Environments
Glossary/Definitions
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.)
Copyright 2012-2015 The Center for Health Design. All Rights Reserved.
V1.2 October2015
57
300-Falls Design
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.
V1.2 October2015
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300-Falls Design
Risk Data: Falls
A Safety Risk Assessment for Healthcare Facility Environments
Glossary/Definitions
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.)
Copyright 2012-2015 The Center for Health Design. All Rights Reserved.
IP
V1.2 October2015
Room Layout
B
59
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).
V1.2 October2015
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300-Falls Design
Risk Data: Falls
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
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
V1.2 October2015
Interior
Design/Finishes
B
61
300-Falls Design
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).
Copyright 2012-2015 The Center for Health Design. All Rights Reserved.
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.
V1.2 October2015
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300-Falls Design
Risk Data: Falls
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.
Copyright 2012-2015 The Center for Health Design. All Rights Reserved.
V1.2 October2015
63
300-Falls Design
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.
V1.2 October2015
64
300-Falls Design
Risk Data: Falls
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.
Copyright 2012-2015 The Center for Health Design. All Rights Reserved.
V1.2 October2015
65
300-Falls Design
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.
Copyright 2012-2015 The Center for Health Design. All Rights Reserved.
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)
V1.2 October2015
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300-Falls Design
Risk Data: Falls
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
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.
Copyright 2012-2015 The Center for Health Design. All Rights Reserved.
V1.2 October2015
A
67
300-Falls Design
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).
Copyright 2012-2015 The Center for Health Design. All Rights Reserved.
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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300-Falls Design
Risk Data: Falls
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
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.
Copyright 2012-2015 The Center for Health Design. All Rights Reserved.
IP
V1.2 October2015
69
300-Falls Design
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.
V1.2 October2015
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300-Falls Design
Risk Data: Falls
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
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.
Copyright 2012-2015 The Center for Health Design. All Rights Reserved.
V1.2 October2015
71
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
Copyright 2012-2015 The Center for Health Design. All Rights Reserved.
V1.2 October2015
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)
V1.2 October2015
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.
Copyright 2012-2015 The Center for Health Design. All Rights Reserved.
V1.2 October2015
74
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.).
Copyright 2012-2015 The Center for Health Design. All Rights Reserved.
V1.2 October2015
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.
V1.2 October2015
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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.)
Copyright 2012-2015 The Center for Health Design. All Rights Reserved.
V1.2 October2015
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
Copyright 2012-2015 The Center for Health Design. All Rights Reserved.
V1.2 October2015
78
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.
Copyright 2012-2015 The Center for Health Design. All Rights Reserved.
V1.2 October2015
79
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.
V1.2 October2015
80
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.
Copyright 2012-2015 The Center for Health Design. All Rights Reserved.
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
V1.2 October2015
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.)
Copyright 2012-2015 The Center for Health Design. All Rights Reserved.
V1.2 October2015
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
Copyright 2012-2015 The Center for Health Design. All Rights Reserved.
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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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.
Copyright 2012-2015 The Center for Health Design. All Rights Reserved.
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87
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
Copyright 2012-2015 The Center for Health Design. All Rights Reserved.
V1.2 October2015
88
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).
Copyright 2012-2015 The Center for Health Design. All Rights Reserved.
V1.2 October2015
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
Copyright 2012-2015 The Center for Health Design. All Rights Reserved.
V1.2 October2015
90
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.
Copyright 2012-2015 The Center for Health Design. All Rights Reserved.
V1.2 October2015
91
500-Behavioral Health Design
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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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)
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.
Copyright 2012-2015 The Center for Health Design. All Rights Reserved.
V1.2 October2015
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500-Behavioral Health Design
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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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
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.
Copyright 2012-2015 The Center for Health Design. All Rights Reserved.
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500-Behavioral Health Design
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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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.
Copyright 2012-2015 The Center for Health Design. All Rights Reserved.
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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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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.
Copyright 2012-2015 The Center for Health Design. All Rights Reserved.
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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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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].)
Copyright 2012-2015 The Center for Health Design. All Rights Reserved.
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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).
Copyright 2012-2015 The Center for Health Design. All Rights Reserved.
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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)
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).
Copyright 2012-2015 The Center for Health Design. All Rights Reserved.
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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.
Copyright 2012-2015 The Center for Health Design. All Rights Reserved.
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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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Glossary/Definitions
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.
Copyright 2012-2015 The Center for Health Design. All Rights Reserved.
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
109
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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Security Risk Data
Design Considerations:
Security
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
Copyright 2012-2015 The Center for Health Design. All Rights Reserved.
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
111
600-Security Design
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.
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)
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
600-Security Design
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
Copyright 2012-2015 The Center for Health Design. All Rights Reserved.
V1.2 October2015
A
B
113
600-Security Design
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
Copyright 2012-2015 The Center for Health Design. All Rights Reserved.
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.
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)
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
114
600-Security Design
GEN Site Optimization
V1.2 October2015
A
115
600-Security Design
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
Copyright 2012-2015 The Center for Health Design. All Rights Reserved.
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.
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)
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
116
600-Security Design
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
V1.2 October2015
Building Layout
117
600-Security Design
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.
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)
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.
Copyright 2012-2015 The Center for Health Design. All Rights Reserved.
V1.2 October2015
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
600-Security Design
Building category
GEN
Unit Layout
GEN
Unit Layout
GEN
Unit Layout
GEN
Technology
Integration
GEN
Unit Layout
GEN
Unit Layout
A
119
600-Security Design
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.
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)
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).
Copyright 2012-2015 The Center for Health Design. All Rights Reserved.
V1.2 October2015
121
600-Security Design
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
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
122
600-Security Design
Building category
Rx
Unit Layout
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
Unit Layout
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
Copyright 2012-2015 The Center for Health Design. All Rights Reserved.
V1.2 October2015
123
600-Security Design
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.
Copyright 2012-2015 The Center for Health Design. All Rights Reserved.
Why should this be considered?
(Rationale)
(This cell hyperlinks to references)
Select
Select
Cost
Magnitude
Safe Design Roadmap
Select
Your Priority
Select
Generic Risk
Estimate
Med-Low
Select
Select
Select
Select
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
Sort #
What is being discussed?
(Design Consideration)
Your Risk
Estimate
Project Data
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.
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)
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
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
124
600-Security Design
Building category
Rx
Building
Envelope/Structu
re
HIM
Unit Layout
B
HIM
Technology
Integration
B
ED
Unit Layout
B
635 Ensure that ED cannot be accessed by unauthorized
visitors and personnel at all times.
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600-Security Design
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
Sort #
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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Risk Data: Security
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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)
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
FGI
126
600-Security Design
Building category
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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Glossary-ProjectPhaseDefintions
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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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References
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