A Spill, a Slip, a Hospital Trip

Slips, trips, and falls are an everyday risk at hospitals and comprise one of the top accident categories.

• By John M. Eliszewski
• Nov 01, 2015

Most of us have seen the safety slogan before, "a spill, a slip, a hospital trip," but what happens if you are a hospital employee who experiences a fall due to slipping in a puddle of water inside the employee entrance? With all of the justifiable focus given to the patient experience in a health care setting, sometimes the safety of the hospital staff is overlooked. The same diligence that is used to ensure patient safety needs to be consistently applied to the employee safety program. As a Joint Commission inspector once told me, "If it will make a patient fall, it will make an employee fall."

Understanding the Health Care Regulatory Landscape
The health care industry is one of the most regulated industries in the United States. A Joint Commission study from 1996-1997 found at least 115 agencies are involved in some capacity in regulating healthcare. These agencies include:

• 20 federal agencies
• Five state agencies
• Five local agencies
• 85 private agencies

Major Health Care Regulatory Agencies
Health care is a very dynamic industry. There are three major entities that health care organizations have to follow when it comes to employee and patient safety. These agencies are the Occupational Safety and Health Administration, the Joint Commission, and the Centers for Medicare and Medicaid (CMS). Each has a different area of focus. OSHA deals exclusively with the hospital employee's safety; the Joint Commission is concerned with employee, patient, and visitor safety; and CMS has Conditions of Participation (CoPs) that mandate compliance with federal, state, and local laws. Hospitals must be deemed to be in compliance with applicable federals laws related to the health and safety of patients. They must also be approved as meeting licensing standards established by various organizations, such as the Joint Commission or other accreditation organizations.  

Patients add an additional element of risk, but this article will focus on the health care employees' safety.

OSHA Ramps up Safety Emphasis in Health Care
According to Bureau of Labor Statistics (BLS) accident data, U.S. hospitals recorded nearly 58,000 work-related injuries and illnesses in 2013, which equates to 6.4 work-related injuries and illnesses for every 100 full-time employees. This rate was twice as high as the incident rate for private industry.

On June 25, 2015, OSHA released a memorandum entitled "Inspection Guidance for Inpatient Healthcare Settings." It covers facilities that fall under the North American Industry Classification System Major Groups -- 622 (hospitals) and 623 (nursing and residential care facilities). The document provides guidance for OSHA inspectors conducting programmed, complaint, referral, or severe injury inspections at inpatient health care facilities. The inspections focus on the following hazards that were addressed in the "National Emphasis Program – Nursing and Residential Care Facilities," which expired April 5, 2015:

• Musculoskeletal disorders relating to patient or resident handling
• Workplace violence
• Bloodborne pathogens
• Tuberculosis
• Slips, trips, and falls

Based on OSHA's instructions to its Compliance Safety and Health Officers for identifying hazards while conducting inspections in a nursing and personal care facility, the following areas were highlighted as having higher potential for slips, trips, and falls:

• Slippery or wet floors, uneven floor surfaces, corridor clutter, and areas with inadequate lighting
• Unguarded floor openings and holes
• Damaged stairs and stairways
• Elevated work surfaces with no guardrails
• Inadequate aisles for moving residents
• Improper use of ladders and stepstools

Environmental Tours
An Environmental tour (EC Tour) is a scheduled thorough inspection of the facility to review facility conditions and the overall effectiveness of the environmental safety risks. The EC Tours are required to be conducted per the Joint Commission every six months in patient care areas and annually in non-patient care areas. The EC Tour committee should consist of multidisciplinary team members who have a passion for safety and have experience in the patient environment. Suggested key team members for the EC Tour committee should include representation from the following areas:

• Safety
• Security
• Infection control
• Housekeeping
• Facility engineering
• Clinical engineering
• Administration
• Other areas deemed appropriate

The tour should include the inside of the facility as well as the grounds, parking lots and structures, and sidewalks. There is no right or wrong way to conduct an EC Tour, however, there are several different methods of capturing information that will give you a better understanding of your facility's condition. The first leg of the EC Tour should involve a review of department procedures so that the team can identify variances in policy during the department inspection. The second leg of the EC Tour is to conduct walkthroughs of the areas and observe the conditions firsthand while looking for slip, trip, and fall hazards, such as corridor clutter, poor lighting, damaged floor tiles, and spilled liquids. Also, be on the lookout for "workarounds" during the tour, because these often indicate a breakdown in department protocol. A workaround is where a staff member encounters a roadblock in performing his tasks efficiently and develops a quicker way to solve the problem. Methods to communicate the inefficiencies that prompted the workaround need to be communicated to the staff to avoid these potentially hazardous situations.

The last leg of the EC Tour is conducting staff interviews.  Interviews can be an invaluable source of information to get a true indication of what happens on the floor. The interviews are also a teaching opportunity for the staff.

A great tool to provide consistency on the tours is a department-specific EC Tour checklist. It helps remind the team members what they are required to inspect for in each area and to ensure nothing is overlooked. The most important aspect of the EC Tours is providing feedback and following up with the identified deficiencies in policy adherence or physical hazards. EC Tours of your facility give insight as to where the slip, trip, and fall hazards are present.

Slips, Trips, and Fall Hazards in the Health Care Setting  
Water or contaminants such as grease, oil, and bodily fluids on the floor are one of the leading causes of accidents in health care facilities. When you consider the size of hospitals and their complexity, controlling these hazards is a daunting task.

Most floors when dry are inherently safe, but when these contaminants are present, the floor surfaces can become very slick. Areas of a health care facility where employees are most vulnerable to slips, trips, and falls due to contaminants on the floor are:

• Central supply
• Emergency room
• Intensive care unit
• Laboratory
• Laundry
• Physical therapy
• Radiology
• Surgical suite

Slippery floors due to the frequent washing process are also a constant concern in health care settings. Areas where water can pool, such as any outside entrances during inclement weather, kitchen areas, cafeterias, ice machines, whirlpool tubs, and sinks, are a source for slips. Facility maintenance departments where grease and oil can accumulate on the work area floor can cause slip hazards. Patient interactions that involve water or bodily fluids such as blood, urine, and vomit can make the footing questionable.

Outdoor slip hazards can vary, depending on the climate. Wintery weather will bring snow and ice patches that can cause treacherous walking conditions. Rain will leave surfaces slick and make some parking surfaces more slippery if oil and grease are present. Roof drains that are not properly installed can discharge large volumes of water in the walking path of employees. Plus there are all of the trip hazards associated with the parking lot areas, including in-ground sprinkler heads, raised sidewalks, potholes, and parking stops.

Solutions
OSHA's hierarchy of hazard controls looks at three levels of addressing hazards.  The most desired method removes the hazard at its source through the use of engineering controls. A couple of examples of engineering controls would be the repositioning of roof drains to harmlessly discharge water away from walking surfaces or installing matting in an entranceway to absorb snow, ice, and moisture from employees' shoes. Walk off entrance matting should be long enough to adequately remove moisture and debris from footwear. Having umbrella bags stationed in employee entrances to minimize water being tracked into the facility is another example of an engineering control.

The next type of hazard control is work practice or administrative controls. These types of controls include a documented procedure for employees to cover, clean, or report a spill. Another form of work practice control is preventing employees from being able to walk into wet areas by identifying them with high-visibility warning cones, folding signs, portable gates, and retractable barrier tapes.

The last type of control in OSHA's hierarchy of hazard control pyramid is personal protective equipment (PPE). Wearing shoes in good condition is an important aspect of any comprehensive slip, trip, and fall program. Shoes with slip-resistant soles or slip-resistant shoe covers are critical in providing good traction on flooring that has contaminants on it.

Conclusion
OSHA's top official, Dr. David Michaels, has asked the pointed question: "Who is Taking Care of Those Who Care for Everyone Else?" This article sheds light on this question by raising our awareness of the potential for slips, trips, and falls in the health care environment.

Slips, trips, and falls are an everyday risk at hospitals and comprise one of the top accident categories. The operations that exist within the health care landscape present unique and significant challenges and risk to employees in the industry.  Safety and health are given high priority due to the highly regulated nature of the health care industry. Emphasis needs to be placed on OSHA's hierarchy of controls to ensure a safe work environment for all employees in the health care industry.

This article originally appeared in the November 2015 issue of Occupational Health & Safety.