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Keyes Life Safety

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Fire Drill Observers

by Brad Keyes, CHSP, on Mar 16, 2021 1:00:00 AM

Q: One of our AHJs is looking for verification that all hospital personnel participates in fire drills, not just in the vicinity of the system activation. One fire drill form is not sufficient to verify RACE is properly handled throughout. In large facilities, how is this best accomplished from your experience?

A: This is best accomplished by having trained observers out in other departments/units recording what the staff does during the fire alarm signal. In other words, take your fellow Safety Committee members, provide them with some training on what to look for, and give them an evaluation sheet that they can make some notations on how the staff responded away from the source of the alarm. Do this in as many different departments as you can.

The 2012 Life Safety Code says this about hospital personnel participating in fire drills:

  • All employees shall be periodically instructed and kept informed with respect to their duties (
  • Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions (
  • Employees of healthcare occupancies shall be instructed in life safety procedures and devices (
  • Emergency egress and relocation drills shall be held with sufficient frequency to familiarize occupants with the drill procedure and to establish conduct of the drill as a matter of routine. Drills shall include suitable procedures to ensure that all persons subject to the drill participate (4.7.2)

Your accreditation organization says this about hospital personnel participating in fire drills:

“Staff who work in buildings where patients are housed or treated participate in drills according to the hospital’s fire response plan.”

It is interesting to note that both the LSC and the accreditation organization’s standards says that staff must participate in fire drills in accordance with the fire response plan. So, what does your fire response plan say about the expectations of staff who are away from the scene of the alarm? If the alarm goes off on the 4th floor, what do you expect the staff to do who are located on the 1st floor? Perhaps nothing is an appropriate response. Perhaps getting up and clearing corridors and closing patient room doors is another appropriate response. If your fire response plan expects staff who are away from the scene of the alarm to do something, then you need to send observers out to watch and evaluate them.

It won’t hurt to get signatures of all who participate during fire drills, and don’t forget about those weekend and holiday shifts. Also, the 2012 NFPA 99 Health Care Facilities Code, section now requires fire drills in the OR Surgery on an annual basis.

Readers, if you would like a free copy of a fire drill evaluation sheet, send an email to and put “Fire Drill Evaluation” in the subject line.

Topics:Fire Drills

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