The Hospital Risk Assessment Program is designed to ... - SEHA

Division/ Dept: OMD/HSE 

Ref. No: HSE-I-012 

Section: HSE Issue Date: November 2004 

Subject: Risk Assessment Program Revised on: July 2009 

2 nd Revision: July 2011 

Revision: 1 Page: 1of 7 

POLICY: 

The Hospital Risk Assessment Program is designed to evaluate the impact on patient care as it 

relates to HSE of the buildings, grounds, internal physical systems and safe practices of hospital 

employees. 

The Performance Improvement Plan for the HSE Committee is designed to monitor the level of 

HSE compliance at the hospital, and to identify any situations that detract from our goal of 

providing a safe and secure environment for our patients, employees, medical staff and visitors. 

Inherent in our monitoring is the obligation to take corrective action when a problem is detected 

and to provide follow-up to corrective actions taken.







Risk Assessment 

HAZARD IDENTIFICATION & ASSESSMENT 

Define Hazard Assessment/Management Systems 

Risk management can only be achieved via management of known and potential hazards and this 

requires the definition of a Hazard Assessment/Management System. SEHA / HAAD Facilities 

requires have programs and procedures which: 

- Identify hazardous activities, the potential hazardous event, and consequences. 

- Assess and priorities risks in cost effective manner. 

- Ensure that design of new facilities incorporates HSE risks. 

- Ensure that acquisitions and asset disposal are evaluated for HSE risks. 

- Ensure that HSE hazards from equipment and facility decommissioning are managed. 

It is vital that the programs and procedures which are developed and assessed versus risks, which 

are identified and managed. Continuous improvement is the key to future HSE performance. 

With reference to figure management of hazards is a 4 step closed loop continuous process: 

(1) 

Identify the 

hazard(s) 

(2) 

Evaluate 

Analyse & asses 

the risk 

(4) 

Review & verify 

hazards & risks 

(3) 

Manage the risk 

(to acceptable level)







Procedures 

The following procedures are to be followed when identifying HSE and health hazards, assessing 

their risks and implementing risk control at the SEHA / HAAD HCF. This procedure can be used 

to prevent hazards from occurring or recurring. 

Steps 

1. Hazard Identification 

2. Risk Assessment 

3. Risk Control 

4. Ongoing Evaluation 

Hazard Identification 

Hazard identification is the process of identifying hazards in the workplace or for a work 

procedure. In order to understand what hazard identification involves, it is first necessary 

understanding the nature of hazards. 

Workplace hazards can be divided into six groups; 

 

 

 

 

 

 

Physical Hazards such as noise, electricity, heat and cold; 

Chemical Hazards such as toxic gases, noxious fumes and corrosive liquids; 

Ergonomic Hazards such as the height of a workbench, the shape of a vehicle seat and 

the length of a control lever; 

Radiation Hazards, for example, from x-ray machines, high powered lasers, radioactive 

materials; 

Psychological Hazards such as stress from using equipment without proper training or 

instructions, overwork, or being coerced into using faulty equipment which carries a risk 

of injury; 

Biological Hazards such as syringes containing potentially infected blood, specimen 

containers carrying potentially infected materials and Legionella bacteria and viruses 

from air conditioning systems.







Risk Assessment 

Risk assessment is the process of assessing all of the risks associated with each of the hazards 

identified during the hazard identification process. 

In assessing the risks, three essential steps are taken: 

1. The probability or likelihood of an incident of an incident occurring is evaluated. 

2. The severity of the potential consequences is calculated or estimated. 

3. Based on these two factors, the risk are assigned for risk control through the use of a risk 

rating. 

Risk assessment involves examining and evaluating the likelihood and severity (or consequence) 

of the potential outcomes in order to prioritize risks for control. 

Step One – Consequence 

What might be the consequence of a hazardous event or situation? 

Descriptor 

Fatality 

Major 

Injury 

Minor 

Injury 

First Aid 

Negligible 

Example Detail Description 

Death 

Extensive injuries, lost time injury > 5 days, 

permanent disability (e.g. broken bones, 

major strains) 

Medical treatment required, lost time injury 

from 1 – 5 days (e.g. minor strains) 

First aid treatment where medical treatment 

not required (e.g. minor cuts and burns) 

Incident does not require medical treatment, 

property damage may have occurred







Step Two – Likelihood 

How likely is it that a hazardous event or situation will occur? 

Descriptor 

Very Likely 

Likely 

Possible 

Unlikely 

Highly 

Unlikely 

Description 

It is expected to occur at some time in the 

near future (daily) 

Will probably occur in most circumstances 

(weekly) 

Might occur at some time (monthly) 

Could occur at some time (six months to a 

year) 

May occur in exceptional circumstances 

(five years plus) 

Step Three – Risk Table 

Calculate the degree of risk from the risk table. 

Likelihood 

Negligible 

Injury 

Consequences 

Minor 

Injury 

First 

Aid 

Injury 

Major 

Injury 

Fatality 

Very Likely H H E E E 

Likely M H H E E 

Possible L M H E E 

Unlikely L L M H E 

Highly 

Unlikely 

L L M H H







Step Four – Risk Assessment Outcome 

The result of the risk matrix is compared with the criteria defined below and the required control 

strategies are implemented as outlined in the Risk Control section below. 

E: extreme risk: immediate action required; notify supervisor, Head of School and the HSE and 

Health. If possible, the activity should be ceased immediately. 

H: high risk: notify supervisor and HSE and health representative and implement immediate 

action to minimize injury. 

M: moderate risk: implement immediate action to minimize injury e.g. signs; supervisor 

remedial action required within five working days. 

Risk Control 

Risk control provides a means by which risks can be systematically evaluated against a set of 

control options (the hierarchy of controls) to determine the most effective control method(s) for 

the risk(s) associated with each hazard. This process involves analyzing the data collected during 

the hazard identification and risk assessment processes, and developing a strategic plan to control 

the risks identified. 

The risk control process starts by considering the highest ranked risks, working down to the least 

significant. Each risk should be examined having regard to the "hierarchy of controls". This 

provides a method of systematically evaluating each risk to determine, firstly, if the causal 

hazard can be eliminated and otherwise, to find the most effective control method for each risk. 

The "Hierarchy of Controls" should be used at all times when implementing controls to eliminate 

the hazard or reduce the risk of a hazard causing loss at the University. 

Hierarchy of Controls 

The hierarchy of controls is as follows: 

1. Eliminate the hazard. 

2. Substitute with a lesser hazard. 

3. Use engineering controls to reduce hazard. 

4. Administrative controls such as workplace procedures. 

5. Personal Protective Equipment.







In many cases, it will be necessary to use more than one control method. Back-up controls (such 

as personal protective equipment and administrative controls) should only be used as a last resort 

or as a support to other control measures. 

Ongoing Evaluation 

Monitoring and review is the final stage in the process. It is the means by which risk 

management is kept current and effective, as new hazards and those overlooked in the original 

process are identified and controlled. 

Monitoring and review involves: 

The systematic re-implementation of the original OHS program steps of : 

o Hazard identification 

o Risk assessment 

o Risk control 

This is to ensure that the process was undertaken properly and that, in hindsight, the conclusions 

were correct 

 

 

 

Ongoing monitoring of existing risk control measures to assess their effectiveness in light 

of changes and fluctuations in the workplace. 

Collection of data on any new hazards which may have arisen and the formulation of new 

control measures. 

Reviewing the risk management process to ensure that all new hazards identified are 

controlled.

The Hospital Risk Assessment Program is designed to ... - SEHA

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