Although most OSHA standards only require the business to update policies when things change, we don’t always recognize those changes when they happen. For this reason, there should be a pre-planned review time for all the safety rules in the hospital. Just as we encourage annual health checkups for our patients, an annual review of the safety program just makes good sense.

Start by reading the Hospital Safety Manual. Pay particular attention to the responsible persons named in the plans and make sure they are still the best ones to handle the job. Hand-written changes are acceptable, but the plan should be retyped when the changes start to “clutter” the document. Put a revision date on the new plan and keep the old one for at least 7 years (just like any other business records.)

It’s also a good time to review the status of your staff training:

• First, make sure you have documentation that shows all staff members have received initial safety training. Don’t forget the part-time and seasonal employees in this review.
• Also remember that OSHA standards require employees to receive fire safety refresher training on an annual basis. It’s also a great time to reemphasize some of the rules that the staff has been less than diligent in following!
• Set aside time for a short safety review training session. Don’t forget to keep a record of what was discussed and who attended.

Now’s a great time to give the labeling program a boost, too. Take a look at the labels on all your secondary chemical containers and replace those that missing or not readable.

Take a walk around the building - inside and out. Look for any new safety hazards and any old ones that need additional attention. This periodic physical review of the practice shows that you take safety seriously and that you try very hard to prevent problems before they start!

Finally, keep a record of the review; a simple statement in the Hospital Safety Manual like the one below is usually sufficient.

Sample Annual Review Statement

Use this format to add an annual review page to your Hospital Safety Manual. Type the following statement on a separate page and add it to the front of the manual:

By signing below, I certify that I have reviewed the policies in this Hospital Safety Manual and have made appropriate changes. The updates (if any) have been communicated to the staff by either written memo or verbal instruction. Additionally, a review of the processes and procedures of the practice was made to identify new or previously unrecognized hazards; the results of that assessment are also attached to this certification.

____________________________     __________________________
Signature of Reviewer                                 Date of Review

Back to OSHA Questions Page