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Appendix 4: Workplace Violence - Risk Assessment Form and Samples

Example 1: Care of the Elderly Unit

Section 1: Context Appendix 4: — setting the scene

Location: Hillside General Hospital

Division: Care of the Elderly Unit

Area/Activity/Person:  Mr Patient is currently in Bay 2 and is experiencing increasing terms of confusion and shortness of breath. During these occasions, Mr Patient has shown a strong desire to leave the ward, attacking staff who try and direct him to stay. Note – Mr Patient was a regular smoker prior to admission. Mr Patient wears a hearing aid in each ear as a calming measure, however, he is unable to hear or lip read.

 

Section 2: Identifying Hazards — what can go wrong and who will be affected

Hazard	Something with the potential to cause harm	Persons at risk [√]
A	Communication difficulties, leading to frustration; due to hearing deficit and his inability to lip read.	S [ ] V [ ] P [√] O [ ]
B	Absconding from the unit – possibly through lack of comprehension of the treatment being given.	S [ ] V [ ] P [√] O [ ]
C	Acute aggression towards staff who attempt to prevent patient leaving the ward.	S [√] V [ ] P [ ] O [ ]
D	Nicotine withdrawal resulting in adverse effects to the patient’s stability and aggressive tendencies to staff.	S [√] V [ ] P [ ] O [ ]

S = staff; V = Visitor, P = Patient; O = Other

Section 3: Existing Control Measures —what practical steps are already in place

Hazard	Existing Control Measures
All	No control measures have been introduced at this time

 

Section 4: Evaluating risk — not ‘worse case scenario’; takes into account existing controls

Hazard	Consequence ( 1 – 5 )	X	Likelihood (1 – 5 )	=	Risk Rating (1 – 25 )
A	2	X	4	=	8
B	3	X	2	=	6
C	2	X	2	=	4
D	2	X	3	=	6

 

Section 5: Risk prioritised action plan - applying the hierarchy of controls:

E=eliminate I=isolate M=minimise

Hazard	E /I/ M	Practicable Steps required to further control risk	Responsibility
A+ B	M	As Mr Patient can read and write the most appropriate form of communication is through the use of note-pad and pen. Oral communication should not be used as this aggravates Mr Patient.	Ward matron
A+B	M	Attending employees including doctors, porters, nurses, x-ray staff need to be aware of Mr Patient’s specific communication needs. On leaving the ward a pad and pen must accompany Mr Patient.	Ward matron
A+B+C	I	Do not prevent Mr Patient leaving the ward. Ensure at least one employee accompanies Mr Patient, bringing with them his pad and pen to ensure effective communications	All ward staff made aware at handover.
B	M	Consult with Mr Patient’s wife to ascertain specific triggers for his aggression and suggested controls that can be implemented – ensure the findings are used to inform the review of this assessment	Division manager and ward matron.
D	E	The hospital ward is a ‘no smoking’ area. The use of nicotine patches during Mr Patient’s inpatient stay should be communicated with him and trialled with his agreement. Remember to change the patches as per manufacturer’s instructions.	Mr Patient’s doctor.

 

Section 6: Further Information: cross-sector safety responsibilities

Who is responsible for local monitoring?: Ward matron

Is further competent (clinical risk, manual handling) advice required? Yes / No Comments: Rehab team

Do third parties (agencies) require a copy of this risk assessment for their safety? Yes / No Comments: When attending other internal departments.

 

Section 7: Assessment Sign-Off – assessment monitoring responsibilities

Assessor’s name: Mrs Ward assessor

Date of assessment: 10 September 2005

Assessor’s signature:

Review: (tick one) daily weekly monthly yearly

Reassessment date: 11 October 2005

Manager’s signature:

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