Building a fire safety culture in health facilities

Dr David Gold and Neil Vincer, from IOSH, discuss how organisations can ensure that a sustainable workplace fire safety culture is incorporated to all staff in a hospital setting

Health care workers play a vital role in today’s society, especially considering the ageing populations in many countries that need or will need care either in health care facilities or at home. All members of the health care profession should continually work in a safe and healthy environment carrying out practices that do not put them at risk of injury or ill health. A previous article in this journal examined several of the risks health care professionals face and described measure to eliminate or mitigate those risks.

Occupational safety and health promotes the concept of a safety culture. A safety culture exists when workers throughout an organisation not only continually look out for their personal safety and health, but also look out for the safety and health of others including their co-workers. The concept of a safety culture embraces positive values, including attitudes and knowledge. Professionals working in the health care field, by the nature of their profession and their duty of care, extend the safety culture to protect their patients, some of whom cannot look after themselves, especially during an emergency situation.

The American Bureau of Shipping (ABS) proposes eight categories of leading indicators of a safety culture. The following are leading indicators, adapted from the ABS publication, that fall under the eight categories:

Communication about fire safety
The organisation: develops means of communication including the provision of information sheets, newsletters, and toolbox talks, in local languages regarding incidents and lessons learned about fire safety; includes adequate fire safety information as part of new employee induction providing; and shares with employees, contractors and visitors policies, goals, directives and standards addressing fire safety.

The organisation: involves all workers and contractors in fire safety; and develops and promotes for all workers means to bring fire safety to their home.

The organisation: documents the presence and use of a fire safety worker feedback mechanism; and ensures that information about fire-related risks, incidents, and near misses are communicated to workers.

Mutual trust
The organisation establishes a fair system for fire-related incident investigation.

Problem identification
The organisation: puts in place and maintains a policy mandating fire safety procedures and instructions with specific information on job-specific fire safety; establishes and maintains a policy and procedures for reporting unsafe fire-related conditions and actions; and ensures that fire safety-related checklists are regularly updated.

Promotion of safety
The organisation: has fire safety-related safety goals and objectives; has a procedure making all fire-related incident investigation findings available to workers; and requires senior management attend meetings related to fire safety.

The organisation: regularly implements fire training programmes for different category of emergencies; puts in place and maintains an organisational-wide effort to continually promote fire safety awareness; and puts in place and maintains training programmes for assessing risks related to fire.

Safety awareness
The organisation provides fire safety awareness training and puts in place procedures to document the training.

Management of health care facilities, whether public or private, has an upstream responsibility, a duty of care, to ensure all aspects of safety, health and fire safety are addressed and reinforced for health care professionals, patients, visitors, contractors and others visiting the facility.

This publication draws from a publication Fire Safety Risk Assessment: Health care premises that can be downloaded here. The authors recommend carefully examining this document and its associated checklists.

Fire prevention
What managers need to consider about fire prevention is keeping apart the three elements that when combined in the right proportions can create fire or explosions. The three elements are heat (also known as source of ignition), fuel (also known as combustible or flammable materials in solid, liquid or gas form) and oxygen (bearing in mind the level of oxygen we need to breathe is the same level that supports fire).

An essential element of fire risk assessment, if properly done by an appropriately trained competent person identifies, assesses and proposes control measures to either eliminate or control the risk and follows up where and when these elements, in combination, may increase the risk of fire. For example, bedding is common in a health care environment, and is a source of fuel. Oxygen is ever present, and may be more concentrated around some patients, but the risk of fire is minimal if there are no sources of heat. Therefore bedding, either laundered or soiled, should always be stored away from sources of heat.

In health care facilities areas, such as laundries, laboratories, pharmacies, heating plants and waste disposal areas may have elevated fire risks as the potential for the combination of fuel and heath may be elevated. Even health care facilities that may be designated smoke free campuses may be at risk from ignition from open flames such as cigarette lighters, matches or discarded cigarettes due to a perceived urgent need to smoke by staff, patients, visitors or contractors who will try to find an area where they can smoke unobserved.

Consider the following situation that occurred in a health care facility.

A fire occurred in a hospital where a cleaning worker, rather than brave the cold and move to a designated smoking area outside of the hospital campus, would frequently go into a linen storage area to sneak a cigarette. One day she lost her live cigarette in a partially full laundry bin which caught fire. A great deal of smoke first activated the alarm system initiating an activation of the emergency action plan. A sprinkler head in the laundry storage area eventually extinguished the fire. The smoker, however, needed to be hospitalised due to smoke inhalation as a result of the fire. The floor was evacuated, the fire service responded but minimal damage occurred.

Health care facilities may also have flammable and combustible liquids or gases in different areas of the facility. Laboratories, operating theatres and casualty, maintenance areas, pharmacies as well as supply areas may stock certain products that when exposed to heat may ignite. Also shipping and receiving areas may have combustible waste that needs to be disposed of.

In the Journal Patient Safety in Surgery, Batra and Gupta described how the use of an alcohol-based substance in the presence of electrosurgical equipment created a fire in an operating theatre.

The basic philosophy which needs to be vigilantly followed is to keep heat, fuel and oxygen apart.

Building a fire safety culture in health facilities

Fire protection
Fire protection in health care facilities includes what is needed to protect the patient, workers, visitors and others from the danger of fire. This includes, but is not limited to: the preparation and keeping up-to-date a number of required and essential documents; systems to detect smoke or heat; automatic fire suppression systems such as automatic sprinkler systems; mechanisms to notify the local emergency services that an alarm has been activated; systems to notify staff, patients, visitors and others to evacuate; a system of designated primary and secondary emergency escape routes from all areas of the building; designated external emergency assembly areas; a system to account for evacuated patients, staff, visitors and others; mechanisms to provide continuity of care during an evacuation including agreements with other facilities to provide shelter as necessary; staff training on evacuating patients; regular drills and exercises involving the local emergency services; fire related doors including self-closing mechanisms to limit the spread of smoke and fire by-products; stairways that are protected from smoke; and a compilation of safety data sheets that is readily available and describes the properties of hazardous substances used in the facility.

Although the 14 above-mentioned points are examples of essential fire protection elements, it would take more than a journal article to provide detailed information on each one. We would, however, like to call your attention to a few.

It is essential that there are designated emergency escape routes from all areas of the facility to a place of safety. These routes need to be clearly marked, continually unobstructed, well lit, and unlocked. In consultation with the local fire service, the emergency action plan may call for a phased evacuation, not evacuating all patients and staff at once. In some facilities there are designated areas of refuge (with specific engineering criteria) where evacuees wait for assistance from the emergency services.

An emergency escape route may be part of a normal passageway. Often times the secondary emergency escape routes may be passageways and doors that are not in constant use. In some locations, during the winter season, the doors leading outside may be obstructed by snow. It is essential that all designated escape routes are regularly inspected by a designated person and are continually unobstructed.

Evacuation in a health care facility includes both ambulatory and non-ambulatory patients, although during a fire emergency, ambulatory patients may become non-ambulatory due to fear or stress. Moving non-ambulatory patients in beds may not be feasible. In a number of facilities an evacuation sheet is used. It is essential, however, that health care facility staff are trained in how to evacuate a patient using a drag sheet or other evacuation mechanisms that the facility uses.

Patients, staff, visitors and others need to be accounted for once outside of the building. A means of accounting for who is missing needs to be set up and described in the emergency action plan. There also needs to be a means of rapidly informing the responding emergency service who is not accounted for and where and when they were last seen. This will greatly influence the search and rescue strategy of the emergency service.

Planning for fires and other emergencies needs to be done in advance. As essential documents are drafted, proposed measures need to be tested and revisited as necessary. When new procedures are designed and implemented and new equipment, materials and products are brought into the facility, plans need to be re-examined and adjusted as necessary. Desk top exercises and evacuation drills are essential means for determining whether plans are effective.

Key to successful emergency planning is the training and education of all staff including hands-on practical training so that their respective roles in a fire and evacuation become second nature. It is also a good practice to provide all staff, during induction, a thorough briefing on fire safety and regular refresher training.

Visitors, contractors and others should also be provided information about fire safety when they work in or visit the facility.

Essential documents
This article suggest three essential documents that should be continually reviewed and updated as necessary. The three documents are the fire risk assessment, the emergency action plan and the fire prevention plan. All documents should be drafted in concert with the local emergency services and should be reviewed with these services before finalised.

The fire risk assessment
According to the publication Fire Safety Risk Assessment: Health care premises and the (UK) Health and Safety Executive, there are five steps for carrying out a risk assessment: identify fire hazards; identify people at risk; evaluate, remove, reduce and protect from risk; record, plan, inform, instruct and train; and review.

The Fire Safety Risk Assessment: Health care premises publication goes into further guidance of what needs to be considered on the following topics: fire risks and preventative measures; fire-detection and warning systems; firefighting equipment and facilities; escape routes and strategies; emergency escape lighting; signs and notices; recording, planning, informing; and instructing and training.

Strong consideration should also be given to who is carrying out the risk assessment for the facility. Criteria for the competencies of fire risk assessors can be found in the following document.

The London Fire Brigade, on its website, publishes guidance in choosing a competent risk assessor.

The Institute of Fire Engineers maintains a registry of fire risk assessors as well as a list of institutions offering fire risk assessment training.

The emergency action plan
An emergency action plan is based on a risk assessment, carried out by a competent risk assessor. Partially based on a document from the (US) Occupational Safety and Health Administration (OSHA) an Emergency Action Plan must contain the following elements: a description of types of emergencies that could occur to the facility; means of reporting fires and other emergencies; levels of emergencies and criteria for escalation; evacuation procedures and emergency escape route assignments; procedures for staff who remain in order to assist patients and others or shut down critical functions before they evacuate; procedures for accounting for all patients, employees and visitors after an emergency evacuation has been completed; rescue and medical duties for employees performing them; names or job titles of persons who can be contacted; agreements with emergency services; agreements with other facilities to accept evacuated patients; and timing for the regular review of the emergency action plan.

The Fire Prevention Plan
A number of organisations also publish a fire prevention plan. It is based on the fire risk assessment and includes a description of sources of fuel and sources of ignition at the facility that could cause or contribute to the spread of fire. The plan also describes alarm systems and fire extinguishing systems. The plan should also describe protection dealing with the detection, the outbreak and the spread of fire.

Based on HSE guidance the plan should also provide clear instructions on eliminating or controlling sources of heat, diminish the amount of combustible or flammable materials. The plan should describe measures to: avoid or control sources of ignition; eliminate or minimise combustible or flammable materials; separate sources of heat from fuel; detect fires and raise the alarm; minimise the spread of fire, smoke, or bi-products of fire; and take action on discovering a fire or when a fire alarm is activated.

The Institution of Occupational Safety and Health (IOSH) is concerned about fire safety at work. A Sectoral Group, the Fire Risk Management Group, offers a series of seminars for occupational safety and health professionals on fire safety related issues including: The role of the occupational safety and health professional in dealing with fire safety; dealing with complacency when an evacuation alarm is activated; Risk assessment and emergency action planning; and dealing with the handicapped during a fire evacuation.

For further information email:

IOSH also offers two training courses: Fire Safety for Managers and Fire Safety Awareness.

Even in the most up-to-date health care facility with the most modern fire safety equipment, fires can and do occur. It is essential that fires are prevented and that we do everything that is reasonably practicable to protect ourselves, workers, patients, visitors, contractors and others from the dangers of fire. Empowering the health care professional and other staff with information and training on preventing fires and procedures should a fire occur will help build a culture of fire safety in the organisation. A clearly demonstrated commitment by senior management has also been proven to further strengthen this culture.

Everyone needs to understand the risks of fire and the means to either eliminate the risk or mitigate it to an acceptable level

Dr David Gold, CFIOSH, is vice president of the Institution of Occupational Safety and Health (IOSH) and former chair of the IOSH Fire Risk Management Group. Neil Vincer, CMIOSH is the current chair.

Further Information:

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