August 30, 2011 | | Comments 5
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And now for something completely…the same

Time for a quick roundup of some recent survey trends:

  • We’ve talked about the overarching issues with weekly testing of plumbed eyewash stations any number of times over the years and I am always happy to respond to direct questions. The key element here is that if your organization is not conducting an at least weekly testing regimen for your plumbed eyewash stations and has not documented a risk assessment indicating that a lesser frequency is appropriate, it will likely be cited. My consultative advice: If you’re not testing at least weekly, please do so, or do the risk assessment homework.
  • With the extra life safety surveyor time during survey, the likelihood of encounters with frontline staff is on the rise. And apparently, it is not enough for folks to know what they are doing, but there is also an expectation that they will understand why they do what they do, primarily in the context of supporting patient care (which we all do—everything that happens in a hospital can trace back to the patient). I guess it won’t be enough for folks to be able to respond appropriately when asked how they would respond to a fire. They also need to understand how their response fits into the grand scheme of things. I really believe that folks understand why their jobs are important; we just need to prepare them for the question. Probably more on this as it develops.
  • 96 bottles of beer on the wall, 96 bottles of beer—but will that be enough beer to last 96 hours (I guess it depends on how thirsty you are)? So the question becomes this: If a surveyor asks to see your 96-hour capability assessment, what would you do, and perhaps most importantly, can you account for it in your Emergency Operations Plan? My general thought in this regard is that the 96-hour benchmark would be something that one would re-visit periodically, just as you would your hazard vulnerability assessment, in response to changing conditions, both internal and external.
  • As a final thought for this installment, please make sure that you (that would be the royal “you) are conducting annual fire drills in all those lovely little off-site locations listed as business occupancies on your Statement of Conditions. And make very sure that staff is aware that you are conducting those fire drills. There’s been a wee bit of an upsurge in fire drill findings based on the on-site staff not being able to “remember” any fire drills, in some instances, for several years. The requirement is annual and I don’t think any of us wishes to get tagged for something as incidental as this one.

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Steve MacArthur About the Author: Steve MacArthur is a safety consultant with The Greeley Company in Danvers, Mass. He brings more than 30 years of healthcare management and consulting experience to his work with hospitals, physician offices, and ambulatory care facilities across the country. He is the author of HCPro's Hospital Safety Director's Handbook and is contributing editor for Briefings on Hospital Safety. Contact Steve at

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  1. Greetings Steve,
    Since you mentioned the eyewashes, what about the emergency shower? The new ANSI regulations looks as if it wants it tested weekly, but if it is a self-contained shower holding over 50 gallons of water, how often should it be tested (dumped)?
    Currently the shower is checked once a month for rust, buildup, and leaks, and the shower is dumped annually but is this enough?
    Melissa O

  2. Steve MacArthur

    Hi Melissa,

    As far as the self-contained units go, the guidance from ANSI is to visually check to determine if flushing fluid needs to be changed or supplemented, and that the inspection should be conducted in accordance with maunfacturer instructions. The standard does go on to say that “all” emergency showers shall be inspected annually to ensure that the unit is in compliance with the requirements in effect at the time of installation, so there is a performance element involved that can’t be ignored.

    Hope this helps

  3. Steve,
    What’s your take on the issue of locking doors for nurseries,infant and peds areas? It seems that a strict interpretation of code will say no locks unless “patient needs” are involved (psych units, etc.). I would liek to inteerpret child abduction prevention as a key component to “patient need”.

  4. What area’s are required to have eyewash stations?

  5. What is the required distance an eye wash station has to be available in the endoscopy area in an acute care hospital.

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