When hazards have been identified an assessment of the possible outcomes following exposure, and the likelihood of it happening, needs to be undertaken. This is known as a risk assessment. The nature of the risk assessment will depend on the type of hazard, information relevant to the hazard and the available resources [7] This process should assist in determining the severity of the risk, the effectiveness of any existing control measures, the actions which should be taken, and the level of urgency.

Once hazards have been identified and risk assessed the next step is the development of control strategies . A hierarchical approach provides a range of options for controlling risk. These range from the most to the least preferred [9] As a general principle, the higher the level of assessed risk (death or serious injury) the higher up the hierarchy the control strategy should be (elimination or substitution). In descending order the preferences are:

Note: where elimination is not possible controls are often used in combination—for example a noisy workplace may introduce engineering (noise dampening), administrative (job rotation) and PPE controls (hearing protection.

Manual handling tasks associated with patient care are an integral part, and a high risk aspect, of healthcare; they often result in musculoskeletal disorders . An example of a hazardous task is transferring a patient (who is unable to assist) from a bed to a barouche. Table 9.2 illustrates the use of the control hierarchy in the development of strategies to manage this task safely.

An evaluation of control measures determines whether they are effective in controlling the risk. It also ensures that their introduction has not created an unforeseen outcome—e.g. the introduction of a new risk in another work unit. Reviewing risk controls is an ongoing process. Any change to the work environment, such as the purchase of new equipment or the identification of new hazards, generally requires a review of existing control measures.

The safety culture of an organisation is an important concept. It has been defined as “the product of individual and group values, attitudes , perceptions, competencies and patterns of behaviour that determine the commitment to, and the style and ­proficiency of, an organisation’s health and safety management system” [10]. It is more than the existence of a health and safety system and reflects the everyday context within which hospital staff work.

Senior staff and managers set the tone of the safety culture at the workplace and have a key role in safety promotion. Their activities reveal their beliefs about safety more strongly than their words, thus employees can determine managers’ attitudes to safety and follow their lead. While there may be an overall organisational safety culture, workgroups within an organisation may have their own discrete culture [11]. Some teams foster a collaborative and reporting culture. Others foster a blame culture. There is a correlation between poor (negative) safety culture and work injury [11]. Organisations with a positive safety culture are characterised by communications founded on mutual trust, by shared perceptions of the importance of safety and by confidence in the efficacy of preventive measures [10].

A positive safety leader will work proactively to promote safety, consult with staff, encourage the reporting of hazards and facilitate the implementation of controls. However, this frequently relies on the provision of adequate resources and staffing levels .

The most prevalent of occupational risks in healthcare is the moving and handling of patients and equipment and the adoption of sustained or static postures. Injuries related to these activities result in musculoskeletal disorders—predominantly in the lower back. These are among the most frequent and costly of work-related injuries [12] and have been the focus of numerous interventions and reviews. Despite consistent evidence that technique training in isolation has little to no effect on injury rates this remains the most commonly used intervention [13–15]. Where evidence for its effectiveness does exist it is as part of a multi-component intervention including exercise [16] and risk assessment programs [14].

Reasons for the ineffectiveness of training may be related to the inadequacy of the techniques taught or to the inability of the training to change ingrained behaviours [15]. Other reasons may also be due to the failure of such training programs to address the non-physical factors such as work organization and job satisfaction [17] which have been linked with both the severity and prevalence of back pain [18–21].