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Protect the lives of older people – check your equipment and prevent safety failures


A resident fell from a hoist failure and sustained severe injuries and later died. The Coroner made a number of recommendations. 

Read the Aged Care Quality and Safety Commission clinical alert on 23 January 2023. 

Hoists enable the resident to transfer safely and reduce the risk of injury to staff when used correctly. 

Check that all personnel providing direct care (including agency staff) have been observed and deemed competent in their use which includes knowing the weight limits and routine safety checks prior to use and this is documented in the education records.

Check that maintenance personnel have up to date records of routine servicing of hoists.  Ensure that hoist technicians are aware of this clinical alert and check for specific nut and bolt combinations at the join of the load-bearing arm or frame and the preventative safety mechanisms that need to be in place such as the adhesive or split pin arrangement.
Consider undertaking an audit of all hoists in the service and the competency in their use. 

Key points:

    • Have your preventative maintenance schedules reviewed and report regularly through your governance processes. Check that:
      • All equipment is checked as per manufacturer’s guidelines, servicing arranged and follow up actions completed. Equipment checks completed and dates for servicing are clearly marked on the device. 
      • Do not have unchecked or out of service equipment available, ensure it is tagged and away from resident areas. 
    • Ensure that all personnel using the equipment are competent to do so. 
      • Have records of competency assessment and keep these up to date with refresher training. Competency assessment should also include knowing how to check equipment for safe use, how to report and remove equipment from use if found to be faulty or suspected to be faulty. 
    • Review the organisation’s policies and processes for ensuring safe use of all equipment and devices. As outlined in the clinical alert, equipment included:
      • Mobility and lifting devices
      • Electrical, gas, air conditioning and heating equipment
      • Medical monitoring and treatment equipment devices
      • Fire equipment and mechanisms such as alarms, extinguishers and fire doors
      • Any other equipment that can put any person at risk.
    • Report regularly on equipment and the preventative and reactive maintenance in the service at the leadership meetings. 
    • Log all incidents or near misses in the organisations incident management system and follow the process of reporting, investigation and quality improvement. 

The Aged Care Quality and Safety Commission have issued seven clinical alerts since May 2022. Keep up to date by monitoring for clinical alerts on the Commission website and reporting these alerts through your education program and governance meetings. 

Past alerts are: 

    • Keeping residents safe this summer. 
    • First aid and choking
    • Incontinence associated dermatitis and pressure injury
    • Behaviour support plans
    • Impact of COVID-19 sub-variants
    • Heaters and burns. 

Dr Maggie Haertsch

Aged Services, Interim, Compliance Remediation, Certified Chair and Advisory Boards in Aged Care Specialist

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