Capstone: a care unit safety walk

This last lesson brings the course together in one practical task: a safety walk of a care unit. A safety walk is a planned inspection in which a small team walks through a unit, looks at it with the hazards of this course in mind, talks to the people working there, records what it finds and turns the findings into actions. It is the single most useful habit a unit can build, and it uses every lesson: the hazard groups of Lesson 1, the duties of Lesson 2, the rating method of Lesson 3, and the specific hazards of Lessons 4 to 10, with Lesson 11's reports as the background.

The lesson follows a walk of 4 West and the Birch home area at Maple Court, carried out by Tom, Amira, Sarah, Lina and Marta, with Kevin joining for part of it.

Planning the walk

The safety committee at Northbridge inspects a different part of the hospital every month. A unit safety walk is more focused: it covers one unit in depth, it includes staff who work there, and it is timed for when the unit is busy. Tom and Sarah plan the walk a week ahead.

• Who: a worker member of the committee, the unit manager, a frontline worker from the unit on each shift, and someone from environmental services. A transporter or a lab assistant who visits the unit often brings a useful outside view.
• When: on a weekday morning at about 1000, when care, discharges, rounds and cleaning are all happening, and a shorter second walk at night, because many hazards only appear then.
• What to bring: the checklist, the last walk's findings, the unit's injury and near-miss reports for the past six months, a flashlight, and gloves and hand rub.
• What to respect: patient privacy and dignity. The team does not go into rooms where care is under way, photographs only equipment and spaces with no patients in view, and follows the isolation sign on every door.
• What to read first: the reports. Knowing that 4 West had four slips near the north bathroom and two needlesticks in the med room tells the team where to look hardest.

The checklist

Northbridge's unit safety walk checklist has ten sections, one for each group of hazards in the course and its support areas. Each section has a few items, and some items are marked critical: if any of them fail, they are fixed or controlled before the team leaves the unit.

Some example items from each section:

Talking to the people who work there

A checklist finds things. Conversations find the reasons behind them. At each stop, the team asks the staff working there a few short questions, chosen so that people can answer honestly without feeling tested:

• What is the hardest part of your shift from a safety point of view?
• Is there anything you have reported that has not been fixed?
• What do you do when the lift, the alarm or the right PPE is not there?
• If you could change one thing about this unit to make it safer, what would it be?
• Do you know how to report a near miss, and have you heard back when you did?

On 4 West, a certified nursing assistant from the float pool tells them she was never shown where the unit's portable lift is kept. A night nurse says the staff alarms often fail their test at the start of the night shift because the chargers in the nursing station are unreliable. Marta says nobody tells environmental services which rooms have patients with violence flags. None of these would have shown up on a checklist alone.

Scoring the walk

After the walk, Amira enters the results into a short script that scores each section, lists the failed critical items and compares the unit with its last walk.

# Unit safety walk results: section -> list of (item, result, critical)
# result: "Y" pass, "N" fail, "NA" not applicable
walk = {
 "Exits and emergency":  [("exits clear", "Y", True), ("extinguishers", "Y", False), ("evac sled", "Y", False)],
 "Floors and slips":     [("no spills", "Y", False), ("drip trays", "N", False), ("cords routed", "N", False), ("mats", "NA", False)],
 "Patient handling":     [("ceiling lifts working", "Y", True), ("slings all sizes", "N", False), ("mobility boards", "Y", False)],
 "Infection and PPE":    [("isolation carts stocked", "N", True), ("signs current", "Y", False), ("N95 sizes", "Y", False), ("hand rub", "Y", False)],
 "Sharps":               [("below fill line", "Y", True), ("safety devices", "Y", False), ("no stray sharps", "Y", False)],
 "Chemicals":            [("labels ok", "Y", False), ("SDS access", "Y", False), ("eyewash flushed", "N", True)],
 "Violence prevention":  [("alarms tested", "N", True), ("care plans", "Y", True), ("security number", "Y", False)],
 "Fatigue and staffing": [("breaks taken", "N", False), ("no shift over 16 h", "Y", False), ("schedule check", "Y", False)],
 "Support rooms":        [("heavy items mid-height", "Y", False), ("dirty utility", "Y", False), ("waste streams", "N", False)],
 "Reporting and info":   [("board current", "Y", False), ("staff know how", "Y", False), ("last actions closed", "N", False)],
}

total_pass = total_items = 0
critical_fails = []
for section, items in walk.items():
    scored = [(i, r, c) for i, r, c in items if r != "NA"]
    passed = sum(1 for i, r, c in scored if r == "Y")
    total_pass += passed; total_items += len(scored)
    print(f"{section:22} {passed}/{len(scored)}")
    critical_fails += [f"{section}: {i}" for i, r, c in scored if r == "N" and c]

score = round(100 * total_pass / total_items)
print(f"\noverall: {total_pass}/{total_items} items passed, score {score} out of 100 (last walk: 74)")
print("critical items to fix before leaving the unit:")
for f in critical_fails:
    print("  *", f)

Exits and emergency    3/3
Floors and slips       1/3
Patient handling       2/3
Infection and PPE      3/4
Sharps                 3/3
Chemicals              2/3
Violence prevention    2/3
Fatigue and staffing   2/3
Support rooms          2/3
Reporting and info     2/3

overall: 22/31 items passed, score 71 out of 100 (last walk: 74)
critical items to fix before leaving the unit:
  * Infection and PPE: isolation carts stocked
  * Chemicals: eyewash flushed
  * Violence prevention: alarms tested

4 West scores 71, three points below its last walk, and three critical items fail: an isolation cart missing gowns in two sizes, an eyewash station in the dirty utility room that has not been flushed for three weeks, and staff alarms that failed their test. Before the team leaves, Sarah has the isolation cart restocked, Marta flushes the eyewash and adds it to her weekly round, and the charge nurse swaps the failed alarms for spares from the security office. The rest go into the action plan.

From findings to actions

A walk that ends with a list of problems has done half the job. The other half is the action plan: each finding with a rating, a control chosen as high on the hierarchy as is practical, an owner, a date, and a way of checking it is done.

The plan goes to the safety committee and is posted on the unit's safety board, so that the staff who were asked for their views can see what is being done about them. The two actions still open from the last walk are a warning sign: a walk that keeps finding the same problems teaches people that walks are for show.

The Birch home area

The same team walks the Birch home area at Maple Court the following week, with Lina as the frontline member. The tub room changes from Lesson 3 are in place and working. The new findings are different from 4 West's: a resident's room cluttered with furniture brought from home, which makes transfers awkward; two residents whose responsive behaviors have changed but whose care plans have not been updated; a staff room with no window that the night staff use for breaks with the lights off; and a medication cart with no lock on its sharps drawer. The walk scores 76. Because Maple Court is a home as well as a workplace, some controls, such as asking a family to remove a piece of furniture, take a conversation rather than a work order.

For supervisors: walk with your committee

If you manage a unit, take part in its safety walks yourself rather than receiving the results. You will see what your staff see, you will hear what they tell the committee, and you will be the person who can fix most of it on the spot. Walk at night at least once a year. Close every action before the next walk, or say why you cannot. Thank the people who spoke up, by name if they are happy for you to. The best predictor of whether a unit gets safer is not the score of its first walk but whether the second walk finds fewer of the same problems.

Where the course goes next

This course has introduced the main hazards of healthcare work. The five courses that follow it in the Healthcare Safety program take the biggest ones in depth, using the same hospital and the same people: HSE-391 Safe Patient Handling and Mobility, HSE-392 Sharps Safety and Bloodborne Pathogens, HSE-393 Workplace Violence Prevention in Healthcare, HSE-394 Hazardous Drugs, Chemicals and Radiation in Healthcare, and HSE-395 Healthcare Emergency Codes and Preparedness.