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    Implementation of Disaster Plan Review Sheet

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    ngurah_wardana
    This document summarizes the implementation of a disaster plan at a hospital. It describes the type of disaster, whether it was internal or external, and provides details on staffing, department responses, and critiques of the response. Key information includes that the disaster plan was implemented on a specific date for an unspecified reason. Departments were adequately staffed in response. Overall implementation of the plan was rated as excellent, good, or fair. Suggestions for improving the plan in the future were provided.

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    Implementation of Disaster Plan Review Sheet

    Uploaded by

    ngurah_wardana
    24 views4 pages
    This document summarizes the implementation of a disaster plan at a hospital. It describes the type of disaster, whether it was internal or external, and provides details on staffing, department responses, and critiques of the response. Key information includes that the disaster plan was implemented on a specific date for an unspecified reason. Departments were adequately staffed in response. Overall implementation of the plan was rated as excellent, good, or fair. Suggestions for improving the plan in the future were provided.

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    TRAGEDY TOOLS

    Original Title

    01 12 Tragedy Tool 1

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    This document summarizes the implementation of a disaster plan at a hospital. It describes the type of disaster, whether it was internal or external, and provides details on staffing, department responses, and critiques of the response. Key information includes that the disaster plan was implemented on a specific date for an unspecified reason. Departments were adequately staffed in response. Overall implementation of the plan was rated as excellent, good, or fair. Suggestions for improving the plan in the future were provided.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    24 views4 pages

    Implementation of Disaster Plan Review Sheet

    Uploaded by

    ngurah_wardana
    This document summarizes the implementation of a disaster plan at a hospital. It describes the type of disaster, whether it was internal or external, and provides details on staffing, department responses, and critiques of the response. Key information includes that the disaster plan was implemented on a specific date for an unspecified reason. Departments were adequately staffed in response. Overall implementation of the plan was rated as excellent, good, or fair. Suggestions for improving the plan in the future were provided.

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    of 4

    IMPLEMENTATION OF DISASTER PLAN

    REVIEW SHEET
    Disaster Plan implemented by:________________________________________
    Date of implementation:______________________
    Reason of implementation:
    ____________________________________________________________________________________________
    ____________________________________________________________________________________________
    ____________________________________________________________________________________________
    Was this an internal disaster?

    ______YES ______NO

    Was this an external disaster?

    ______YES ______NO

    Was disaster callback initiated?

    ______YES ______NO

    By whom? _____________________________________________________________
    Type of disaster: (Specify) _________________________________________________
    Briefly, but completely describe the events surrounding the disaster:
    ____________________________________________________________________________________________
    ____________________________________________________________________________________________
    ____________________________________________________________________________________________
    ____________________________________________________________________________________________
    Were communications adequate?

    ___YES ___NO

    Did Chief of Staff place physicians in needed areas?

    ___YES ___NO

    Were any victims or patients transferred?

    ___YES ___NO

    How many? ___________Why?_____________________________________________________


    Were area hospitals notified of the disaster and prepared to help?

    ___YES ___NO

    Was the fire department available?

    ___YES ___NO

    Was the police department available?

    ___YES ___NO

    What community agencies were involved?


    ____________________________________________________________________________________________
    ____________________________________________________________________________________________
    ____________________________________________________________________________________________

    -1-

    IMPLEMENTATION OF DISASTER PLAN


    REVIEW SHEET
    Were hospital patients assessed for discharge if beds were needed for disaster victims?

    ___YES___NO

    How many patients were in the hospital at the time of implementation of the disaster plan? _______________
    How many visitors were in the hospital at the time of implementation of the disaster plan? ________________
    How were the departments staffed?
    DEPARTMENT

    ON DUTY

    CALLED IN

    TOTAL

    ADEQUATE

    Administration

    _______

    _______

    ______

    ______

    Business Office

    _______

    _______

    ______

    ______

    Purchasing

    _______

    _______

    ______

    ______

    Dietary

    _______

    _______

    ______

    ______

    Pharmacy

    _______

    _______

    ______

    ______

    Maintenance

    _______

    _______

    ______

    ______

    Housekeeping

    _______

    _______

    ______

    ______

    Radiology

    _______

    _______

    ______

    ______

    Laboratory

    _______

    _______

    ______

    ______

    Respiratory

    _______

    _______

    ______

    ______

    Physical Therapy

    _______

    _______

    ______

    ______

    Medical Records

    _______

    _______

    ______

    ______

    Nursing

    _______

    _______

    ______

    ______

    Operating Room

    _______

    _______

    ______

    ______

    Central Service

    _______

    _______

    ______

    ______

    Recovery room

    _______

    _______

    ______

    ______

    Medical Staff

    _______

    _______

    ______

    ______

    If there were other categories of individuals in the hospital at the time of implementation of the disaster plan, please list
    the category (e.g., construction workers, etc.):
    CATEGORIES:
    ________________________________________

    NUMBER:
    ______________________________________

    ________________________________________

    ______________________________________

    ________________________________________

    ______________________________________

    -2-

    IMPLEMENTATION OF DISASTER PLAN


    REVIEW SHEET
    Was hospital protocol followed?

    ___YES___NO

    Did staff respond according to protocol?

    ___YES ___NO

    Did supervisory personnel respond according to protocol?

    ___YES ___NO

    Please explain any negative answers:


    _______________________________________________________________________________________________
    _______________________________________________________________________________________________
    How long did it take staff to respond once the disaster plan was implemented?________________________
    How long did it take for supervisory personnel to respond once the disaster plan was implemented?_______________
    Were problems encountered with patients, visitors, or other individuals while the disaster plan was in effect?
    ___YES ____NO
    Please explain problem areas:
    _______________________________________________________________________________________________
    _______________________________________________________________________________________________
    _______________________________________________________________________________________________
    Was corrective action taken at the time the problem(s) were identified?

    ___YES ___NO

    Explain the corrective action:


    _______________________________________________________________________________________________
    _______________________________________________________________________________________________
    _______________________________________________________________________________________________
    Is there a need for future corrective action?

    ___YES ___NO

    Explain:
    _______________________________________________________________________________________________
    _______________________________________________________________________________________________
    _______________________________________________________________________________________________
    Overall implementation, response, and process of the disaster plan was:
    Excellent________

    Good ________

    Fair________

    -3-

    Poor________

    IMPLEMENTATION OF DISASTER PLAN


    REVIEW SHEET
    Could anything be done differently?

    ____YES___NO

    Explain:
    ________________________________________________________________________________________________
    ________________________________________________________________________________________________
    ________________________________________________________________________________________________
    ________________________________________________________________________________________________
    Were monitors selected to evaluate drill?

    ____YES___NO

    Where? _____________________________________________________________
    Immediately after the drill, what groups participated in critique?
    Nurses ____YES___NO

    Physicians ____YES____NO

    Administration

    Fire

    Police

    Hosp. Personnel ____YES___NO

    ____YES___NO

    Ambulance Personnel

    ____YES____NO

    ____YES____NO

    Emergency Management

    ____YES____NO

    ____YES____NO

    Other:
    ________________________________________________________________________________________________
    ________________________________________________________________________________________________
    ________________________________________________________________________________________________
    ________________________________________________________________________________________________
    Title of Person Completing Form:______________________________________________

    ________________________________
    Signature

    ________________________
    Date

    Source: Muskogee Regional Medical Center, Muskogee, Oklahoma. Used with permission.

    -4-

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