Page 1 of 1

Tool 3D: Hazard Report Form

Preventing Falls in Hospitals: A Toolkit for Improving Quality of Care

Word Version [ Microsoft Word file - 30.13 KB]

Background: This tool contains a form for reporting environmental hazards when they are detected. Whereas the inspection checklist (Tool 3C, "Tool Covering Environmental Safety at the Bedside") is for regular, systematic review for fall hazards, this form is for hazards detected incidentally during usual care.

Reference: Falls prevention strategies in health care settings. Plymouth Meeting, PA: ECRI Institute; 2006. Hazard Report Form 13: 248. Reprinted with permission.

How to use this tool: Use this form whenever an environmental hazard is detected. You may need to change the people to whom the hazard is reported based on your local organizational setup. Any hospital employee who enters patient rooms can use this form.

Hazard Report Form

To: Nurse Manager

Equipment or Condition Presenting Hazard: _________________________________________

Location of Hazard: _______________________________________________________________

Date Hazard Reported: _____________________________________________________________

Hazard Reported by (your name): __________________________________________________

Corrective Action Taken (describe what you did to eliminate the hazard):

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

Work Order Initiated (describe what still needs to be done to eliminate the hazard):

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

Work Order Completed on: _________________________________________________________

Work Order Completed by: _________________________________________________________

Action Taken to Eliminate Future Occurrences:

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

Hazard Reported at: ______________________________________________________________

Staff Meeting (date): ______________________________________________________________

Shift Reports (date): ______________________________________________________________

Posting on Bulletin Boards (date): __________________________________________________

Copies of this form must be forwarded to the Risk Manager.

Reprinted with permission. ©2006, ECRI Institute, 5200 Butler Pike, Plymouth Meeting, PA 19462, www.ecri.org .

Return to Roadmap

Current as of January 2013
Internet Citation: Tool 3D: Hazard Report Form: Preventing Falls in Hospitals: A Toolkit for Improving Quality of Care. January 2013. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/systems/long-term-care/resources/injuries/fallpxtoolkit/fallpxtk-tool3d.html